Provider Demographics
NPI:1700860764
Name:WEDEL, PAUL (MD)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:
Last Name:WEDEL
Suffix:
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 1:1025 PENNOCK PL
Mailing Address - Street 2:STE 121
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80524-3257
Mailing Address - Country:US
Mailing Address - Phone:970-624-4439
Mailing Address - Fax:
Practice Address - Street 1:1025 PENNOCK PL
Practice Address - Street 2:STE 121
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80524-3257
Practice Address - Country:US
Practice Address - Phone:970-624-4439
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-02
Last Update Date:2014-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036060589207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036060589Medicaid
IL036060589OtherSTATE LICENSE
IL036060589Medicaid
IL746811Medicare ID - Type UnspecifiedPROVIDER ID# FHC