Provider Demographics
NPI:1629594015
Name:WEDEMEYER, IAN (DPT)
Entity Type:Individual
Prefix:
First Name:IAN
Middle Name:
Last Name:WEDEMEYER
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:380 RIVERWAY
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02115-6407
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1914 CENTRE ST
Practice Address - Street 2:
Practice Address - City:WEST ROXBURY
Practice Address - State:MA
Practice Address - Zip Code:02132-2535
Practice Address - Country:US
Practice Address - Phone:617-323-4377
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-17
Last Update Date:2018-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA23224225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist