Provider Demographics
NPI:1851884985
Name:WEIDER, KIRSTIN IRENE (DO)
Entity Type:Individual
Prefix:
First Name:KIRSTIN
Middle Name:IRENE
Last Name:WEIDER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4600 WOODWARD AVE APT 504
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48201-1896
Mailing Address - Country:US
Mailing Address - Phone:248-804-0497
Mailing Address - Fax:
Practice Address - Street 1:929 BOWMAN RD STE 400
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29464-3237
Practice Address - Country:US
Practice Address - Phone:843-730-4124
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-13
Last Update Date:2023-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
SCDO83809208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program