Provider Demographics
NPI:1700206679
Name:WIEDEL, TAISA VICTORIA (MD)
Entity Type:Individual
Prefix:
First Name:TAISA
Middle Name:VICTORIA
Last Name:WIEDEL
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 1:835 E 18TH AVE STE 110
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80218-1024
Mailing Address - Country:US
Mailing Address - Phone:303-825-4646
Mailing Address - Fax:303-825-3215
Practice Address - Street 1:835 E 18TH AVE STE 110
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80218-1024
Practice Address - Country:US
Practice Address - Phone:303-825-4646
Practice Address - Fax:303-825-3215
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-18
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO56332207Q00000X, 208M00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine