Healthcare Provider Details

I. General information

NPI: 1134582588
Provider Name (Legal Business Name): MATTHEW S WIEDER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2016
Last Update Date: 08/18/2020
Certification Date: 08/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3400 BAINBRIDGE AVE FL 1
BRONX NY
10467-2404
US

IV. Provider business mailing address

310 E 14TH ST
NEW YORK NY
10003-4284
US

V. Phone/Fax

Practice location:
  • Phone: 718-920-2020
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number302783
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: