Healthcare Provider Details

I. General information

NPI: 1376432435
Provider Name (Legal Business Name): MATTHEW T WIEDELL O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2025
Last Update Date: 07/01/2025
Certification Date: 06/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 3RD AVE NE
CROSBY MN
56441-1665
US

IV. Provider business mailing address

1 3RD AVE NE
CROSBY MN
56441-1665
US

V. Phone/Fax

Practice location:
  • Phone: 218-546-5108
  • Fax: 218-546-5736
Mailing address:
  • Phone: 218-546-5108
  • Fax: 218-546-5736

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number4018
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: