Provider Demographics
NPI:1831432947
Name:WIEDERHORN, A ROGER (MD)
Entity type:Individual
Prefix:DR
First Name:A
Middle Name:ROGER
Last Name:WIEDERHORN
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 1:4024 MANSION CT NW
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20007-2149
Mailing Address - Country:US
Mailing Address - Phone:202-333-3918
Mailing Address - Fax:
Practice Address - Street 1:4024 MANSION CT NW
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20007-2149
Practice Address - Country:US
Practice Address - Phone:202-333-3918
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-27
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAVA0101021325208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAVA0101021325OtherDEA# AW7036381