Healthcare Provider Details

I. General information

NPI: 1831428903
Provider Name (Legal Business Name): TODD M. WIEDEL, O.D., PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/18/2009
Last Update Date: 10/10/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30960 GOVERNMENT DR
PEQUOT LAKES MN
56472-1003
US

IV. Provider business mailing address

PO BOX 176
PEQUOT LAKES MN
56472-0176
US

V. Phone/Fax

Practice location:
  • Phone: 218-568-5555
  • Fax: 218-568-8904
Mailing address:
  • Phone: 218-568-5555
  • Fax: 218-568-8904

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number2945
License Number StateMN

VIII. Authorized Official

Name: DR. TODD M WIEDELL
Title or Position: DIRECTOR OF CORPORATION
Credential: OD
Phone: 218-568-5555