Provider Demographics
NPI:1689648438
Name:WIEDEMER, JOSEPH P (MD)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:P
Last Name:WIEDEMER
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:PO BOX 858
Mailing Address - Street 2:MC A410
Mailing Address - City:HERSHEY
Mailing Address - State:PA
Mailing Address - Zip Code:17033-0858
Mailing Address - Country:US
Mailing Address - Phone:800-243-1455
Mailing Address - Fax:
Practice Address - Street 1:1850 E PARK AVE
Practice Address - Street 2:
Practice Address - City:STATE COLLEGE
Practice Address - State:PA
Practice Address - Zip Code:16803-6706
Practice Address - Country:US
Practice Address - Phone:814-235-2480
Practice Address - Fax:814-235-2482
Is Sole Proprietor?:No
Enumeration Date:2006-02-16
Last Update Date:2018-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD065285L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7859104Medicaid
NJ023695B6FMedicare PIN
NJ7859104Medicaid