Provider Demographics
NPI:1801817689
Name:WIEDENFELD, MARK EDWARD (OD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:EDWARD
Last Name:WIEDENFELD
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:905 S JOHN REDDITT DR
Mailing Address - Street 2:
Mailing Address - City:LUFKIN
Mailing Address - State:TX
Mailing Address - Zip Code:75904-4326
Mailing Address - Country:US
Mailing Address - Phone:936-634-4913
Mailing Address - Fax:936-637-7811
Practice Address - Street 1:905 S JOHN REDDITT DR
Practice Address - Street 2:
Practice Address - City:LUFKIN
Practice Address - State:TX
Practice Address - Zip Code:75904-4326
Practice Address - Country:US
Practice Address - Phone:936-634-4913
Practice Address - Fax:936-637-7811
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX5167TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX003FBOtherBLUE CROSS BLUE SHIELD
TX0191736-01Medicaid
TX0191736-01Medicaid
TX003FBOtherBLUE CROSS BLUE SHIELD