Provider Demographics
NPI:1720378375
Name:WEIDERT, MELISSA A (MD)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:A
Last Name:WEIDERT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:A
Other - Last Name:TAAVOLA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:7117 MESILLA LN
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76131-2861
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7117 MESILLA LN
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76131-2861
Practice Address - Country:US
Practice Address - Phone:262-490-9396
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-17
Last Update Date:2023-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXS3476207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100060066Medicaid