Healthcare Provider Details

I. General information

NPI: 1396759783
Provider Name (Legal Business Name): MICHAEL WIEDERKEHR MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2006
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 W RIDGEWOOD AVE SUITE 103
PARAMUS NJ
07652-2359
US

IV. Provider business mailing address

1 W RIDGEWOOD AVE SUITE 103
PARAMUS NJ
07652-2359
US

V. Phone/Fax

Practice location:
  • Phone: 201-857-4200
  • Fax: 201-857-4199
Mailing address:
  • Phone: 201-857-4200
  • Fax: 201-857-4199

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberMA069839
License Number StateNJ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
IdentifierD081378
Identifier TypeOTHER
Identifier State
Identifier IssuerCDS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: