Provider Demographics
NPI:1639151244
Name:WIEDNER, JOHN (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:WIEDNER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16759 MAIN ST
Mailing Address - Street 2:SUITE 203
Mailing Address - City:WILDWOOD
Mailing Address - State:MO
Mailing Address - Zip Code:63040-1232
Mailing Address - Country:US
Mailing Address - Phone:636-458-4800
Mailing Address - Fax:636-594-7500
Practice Address - Street 1:16759 MAIN ST
Practice Address - Street 2:STE 203
Practice Address - City:WILDWOOD
Practice Address - State:MO
Practice Address - Zip Code:63040-1232
Practice Address - Country:US
Practice Address - Phone:636-458-4800
Practice Address - Fax:636-594-7500
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-18
Last Update Date:2016-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR6G00207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOE10053OtherMERCY
MO113996OtherHEALTHLINK
MO16748OtherBCBS
MO4104267OtherAETNA
MO127506OtherGHP
MO0400320OtherUHC
MS000000010043OtherESSENCE
MO110114091Medicare PIN
MOE10053OtherMERCY
MO0400320OtherUHC