Provider Demographics
NPI:1760559264
Name:WIEDER, JEFFREY ALAN (MD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:ALAN
Last Name:WIEDER
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 1:2999 REGENT ST
Mailing Address - Street 2:#612
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94705-2146
Mailing Address - Country:US
Mailing Address - Phone:510-848-1727
Mailing Address - Fax:510-848-8224
Practice Address - Street 1:2999 REGENT ST
Practice Address - Street 2:#612
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94705-2146
Practice Address - Country:US
Practice Address - Phone:510-848-1727
Practice Address - Fax:510-848-8224
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2008-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA710352088P0231X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2088P0231XAllopathic & Osteopathic PhysiciansUrologyPediatric Urology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAYYY49005YMedicaid
CAH39890Medicare UPIN
CAYYY49005YMedicaid