Provider Demographics
NPI:1962470534
Name:WEHLE, FREDERICK JOHN JR (MD)
Entity Type:Individual
Prefix:
First Name:FREDERICK
Middle Name:JOHN
Last Name:WEHLE
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23 MACK BAYOU LOOP STE 200
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32459-2606
Mailing Address - Country:US
Mailing Address - Phone:850-278-3920
Mailing Address - Fax:850-278-3919
Practice Address - Street 1:23 MACK BAYOU LOOP STE 200
Practice Address - Street 2:
Practice Address - City:SANTA ROSA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32459-2606
Practice Address - Country:US
Practice Address - Phone:850-278-3920
Practice Address - Fax:850-278-3919
Is Sole Proprietor?:No
Enumeration Date:2006-03-09
Last Update Date:2021-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME55046208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL063268600Medicaid
FL063268600Medicaid
E97009Medicare UPIN