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General NPI Number Information
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NPI Number | 1720547961
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Entity Type | Individual
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Provider Name | AMANDA WIEDERODER OD
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Gender | Female
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Dates
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Enumeration Date | 03/18/2019
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Last Update Date | 05/28/2025
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Provider Practice Location Address
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Address Line | 230 CONGRESS ST
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City | BOSTON
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State | MA
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Zip | 02110-2409
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Country | US
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Telephone | 617-338-7200
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Fax |
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Provider Business Mailing Address
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Address Line | 65 CHISWICK RD APT 3
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City | BRIGHTON
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State | MA
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Zip | 02135-7134
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Country | US
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Telephone | 989-513-7699
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 5359
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License Number State | MA
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