Provider Demographics
NPI:1598048837
Name:EDWARD L WIEBE DPM PC
Entity Type:Organization
Organization Name:EDWARD L WIEBE DPM PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:L
Authorized Official - Last Name:WIEBE
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:928-226-7555
Mailing Address - Street 1:8 W COLUMBUS AVE
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-3202
Mailing Address - Country:US
Mailing Address - Phone:928-226-7555
Mailing Address - Fax:928-226-0014
Practice Address - Street 1:8 W COLUMBUS AVE
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-3202
Practice Address - Country:US
Practice Address - Phone:928-226-7555
Practice Address - Fax:928-226-0014
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-22
Last Update Date:2011-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ0076213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ2Z6682OtherHEALTHNET
AZ480627039OtherRAILROAD MEDICARE
AZ0353890001Medicare NSC