Provider Demographics
NPI:1790716058
Name:WIEDNER, WILLIAM J (DC)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:J
Last Name:WIEDNER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:931 SE OCEAN BLVD
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34994-2425
Mailing Address - Country:US
Mailing Address - Phone:772-781-1101
Mailing Address - Fax:772-781-1141
Practice Address - Street 1:931 SE OCEAN BLVD
Practice Address - Street 2:
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34994
Practice Address - Country:US
Practice Address - Phone:772-781-1101
Practice Address - Fax:772-781-1141
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-05
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH 7269111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLU65713Medicare UPIN
FL55523Medicare ID - Type Unspecified