Provider Demographics
NPI:1952464604
Name:WEIDEMAN, MIKEL ROBERT (OD)
Entity Type:Individual
Prefix:
First Name:MIKEL
Middle Name:ROBERT
Last Name:WEIDEMAN
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 1:556 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LANDER
Mailing Address - State:WY
Mailing Address - Zip Code:82520-3032
Mailing Address - Country:US
Mailing Address - Phone:307-332-2020
Mailing Address - Fax:
Practice Address - Street 1:556 MAIN ST
Practice Address - Street 2:
Practice Address - City:LANDER
Practice Address - State:WY
Practice Address - Zip Code:82520-3032
Practice Address - Country:US
Practice Address - Phone:307-332-2020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-17
Last Update Date:2020-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY134T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
301173OtherBCBS
WY106723100Medicaid
830260533OtherVISION SERVICE PLAN
T44142Medicare UPIN
WYW301173Medicare PIN