Provider Demographics
NPI:1952334542
Name:WIEDERMANN, JOSEPH G (MD)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:G
Last Name:WIEDERMANN
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 1:310 RIVERSIDE DR APT 310
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10025-4116
Mailing Address - Country:US
Mailing Address - Phone:917-940-4076
Mailing Address - Fax:212-662-0375
Practice Address - Street 1:310 RIVERSIDE DR APT 310
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10025-4116
Practice Address - Country:US
Practice Address - Phone:917-940-4076
Practice Address - Fax:212-662-0375
Is Sole Proprietor?:No
Enumeration Date:2006-07-08
Last Update Date:2021-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA06221700207RC0000X, 207RI0011X
GUMTL-2017-072207RI0011X
GUM-2082207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
GUH110329Medicaid
NY01177233Medicaid
NJ6589502Medicaid
GUH110329Medicaid