Healthcare Provider Details

I. General information

NPI: 1275643223
Provider Name (Legal Business Name): SANDRA WIEDERHOLD MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 10/09/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

670 MALL DR
PORTAGE MI
49024-2878
US

IV. Provider business mailing address

1000 OAKLAND DR
KALAMAZOO MI
49008-1282
US

V. Phone/Fax

Practice location:
  • Phone: 269-327-1900
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301050967
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: