Provider Demographics
NPI:1629074943
Name:WEIDNER, SANDRA L (MD)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:L
Last Name:WEIDNER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2240 RIDGEWOOD RD
Mailing Address - Street 2:STE 100
Mailing Address - City:WYOMISSING
Mailing Address - State:PA
Mailing Address - Zip Code:19610-1167
Mailing Address - Country:US
Mailing Address - Phone:610-376-8691
Mailing Address - Fax:610-376-8745
Practice Address - Street 1:2240 RIDGEWOOD RD
Practice Address - Street 2:STE 100
Practice Address - City:WYOMISSING
Practice Address - State:PA
Practice Address - Zip Code:19610-1167
Practice Address - Country:US
Practice Address - Phone:610-376-8691
Practice Address - Fax:610-376-8745
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD041246E208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA06036OtherEPSDT
PA1123140Medicaid
PA06036OtherEPSDT