Healthcare Provider Details

I. General information

NPI: 1093716359
Provider Name (Legal Business Name): NOEL WIEDERHORN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2005
Last Update Date: 01/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

43 YAWPO AVE
OAKLAND NJ
07436-2714
US

IV. Provider business mailing address

870 PALISADE AVE STE 204
TEANECK NJ
07666-3419
US

V. Phone/Fax

Practice location:
  • Phone: 201-405-0500
  • Fax: 201-337-5585
Mailing address:
  • Phone: 201-928-1093
  • Fax: 201-928-0842

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number25MA02569900
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: