Provider Demographics
NPI:1013396944
Name:WIEDERSUM, SHANNON MCVEY (DO)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:MCVEY
Last Name:WIEDERSUM
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 1:252 W SWAMP RD STE 48
Mailing Address - Street 2:
Mailing Address - City:DOYLESTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18901-2408
Mailing Address - Country:US
Mailing Address - Phone:215-230-9988
Mailing Address - Fax:215-230-9989
Practice Address - Street 1:252 W SWAMP RD STE 48
Practice Address - Street 2:
Practice Address - City:DOYLESTOWN
Practice Address - State:PA
Practice Address - Zip Code:18901-2408
Practice Address - Country:US
Practice Address - Phone:215-230-9988
Practice Address - Fax:215-230-9989
Is Sole Proprietor?:No
Enumeration Date:2015-05-26
Last Update Date:2020-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS019788207N00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program