Provider Demographics
NPI:1770526816
Name:WIEDEMEIER, JEROME J (DC)
Entity type:Individual
Prefix:DR
First Name:JEROME
Middle Name:J
Last Name:WIEDEMEIER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:116 NORTH MAIN ST.
Mailing Address - Street 2:P.O. BOX 323
Mailing Address - City:BUFFALO CENTER
Mailing Address - State:IA
Mailing Address - Zip Code:50424
Mailing Address - Country:US
Mailing Address - Phone:641-562-2020
Mailing Address - Fax:641-562-2924
Practice Address - Street 1:116 NORTH MAIN ST.
Practice Address - Street 2:
Practice Address - City:BUFFALO CENTER
Practice Address - State:IA
Practice Address - Zip Code:50424
Practice Address - Country:US
Practice Address - Phone:641-562-2020
Practice Address - Fax:641-562-2924
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-14
Last Update Date:2010-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAA5749111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA14184OtherBLUE CROSS & BLUE SHIELD
IA0120493Medicaid
3C972BUOtherBC/BS OF MN
3C972BUOtherBC/BS OF MN
IAU4682Medicare UPIN