Provider Demographics
NPI:1932190717
Name:WIEDMAN, MICHAEL SELIG (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:SELIG
Last Name:WIEDMAN
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:PO BOX 9142
Mailing Address - Street 2:
Mailing Address - City:CHARLESTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02129-9142
Mailing Address - Country:US
Mailing Address - Phone:617-726-0287
Mailing Address - Fax:617-726-2894
Practice Address - Street 1:452 PLEASANT ST
Practice Address - Street 2:
Practice Address - City:MALDEN
Practice Address - State:MA
Practice Address - Zip Code:02148-8117
Practice Address - Country:US
Practice Address - Phone:781-322-3224
Practice Address - Fax:781-322-2332
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA25515207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAB26163OtherBCBS MA
MA0193305Medicaid
MA025515OtherTUFTS HEALTH PLAN
MAB26163OtherBCBS MA
MAB26163Medicare ID - Type Unspecified