Provider Demographics
NPI:1598015745
Name:WIEDERHOLD, MARK D (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:D
Last Name:WIEDERHOLD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:9565 WAPLES ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92121-2986
Mailing Address - Country:US
Mailing Address - Phone:858-642-0267
Mailing Address - Fax:858-642-0285
Practice Address - Street 1:9565 WAPLES ST
Practice Address - Street 2:SUITE 200
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92121-2986
Practice Address - Country:US
Practice Address - Phone:858-642-0267
Practice Address - Fax:858-642-0285
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-14
Last Update Date:2012-09-14
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CAG66151207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine