Provider Demographics
NPI:1649250606
Name:WIEDL, ERICA KITCHELL (MD)
Entity type:Individual
Prefix:DR
First Name:ERICA
Middle Name:KITCHELL
Last Name:WIEDL
Suffix:
Gender:F
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:PO BOX 45443
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84145-0443
Mailing Address - Country:US
Mailing Address - Phone:904-202-1032
Mailing Address - Fax:904-376-4107
Practice Address - Street 1:851042 US HIGHWAY 17
Practice Address - Street 2:
Practice Address - City:YULEE
Practice Address - State:FL
Practice Address - Zip Code:32097-2845
Practice Address - Country:US
Practice Address - Phone:904-225-3824
Practice Address - Fax:904-390-7440
Is Sole Proprietor?:No
Enumeration Date:2006-01-18
Last Update Date:2020-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA23432207Q00000X
FLME144522207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine