Provider Demographics
NPI:1801814181
Name:WEDEMEYER, DAVID G
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:G
Last Name:WEDEMEYER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1758 ORANGE AVE
Mailing Address - Street 2:
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92627-3153
Mailing Address - Country:US
Mailing Address - Phone:949-646-7070
Mailing Address - Fax:
Practice Address - Street 1:1758 ORANGE AVE
Practice Address - Street 2:
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92627-3153
Practice Address - Country:US
Practice Address - Phone:949-646-7070
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2011-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC27190111NX0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NX0800XChiropractic ProvidersChiropractorOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
U84616Medicare UPIN
DC27190Medicare PIN
CA5744840001Medicare NSC