Provider Demographics
NPI:1801965496
Name:WEIDNER, EDMUND CHARLES (MD)
Entity type:Individual
Prefix:
First Name:EDMUND
Middle Name:CHARLES
Last Name:WEIDNER
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 1:700 SECOND AVENUE NORTH
Mailing Address - Street 2:SUITE 205
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34102-5701
Mailing Address - Country:US
Mailing Address - Phone:239-263-5400
Mailing Address - Fax:239-263-6661
Practice Address - Street 1:700 SECOND AVENUE NORTH
Practice Address - Street 2:SUITE 205
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34102-5701
Practice Address - Country:US
Practice Address - Phone:239-263-5400
Practice Address - Fax:239-263-6661
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-07
Last Update Date:2010-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0038533207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
D54899Medicare UPIN
FL44171Medicare ID - Type Unspecified