MEDICARE: EDWARD WEIDOW D.O.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084P0800X	Psychiatry Physician	L5610	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	8K5862	OTHER	TX	MCR B NTSH

General Provider Information

NPI Number	:	1033204912
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EDWARD WEIDOW D.O.

Provider Business Mailing Address
First Line	:	PO BOX 70
Second Line	:
City	:	TERRELL
State	:	TX
Zip	:	75160-9000
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1200 E BRIN ST
Second Line	:
City	:	TERRELL
State	:	TX
Zip	:	75160-2938
Country	:	US
Telephone Number	:	972-524-6452
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/04/2006
Last Update Date	:	08/12/2010

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Directions to “ EDWARD WEIDOW D.O.” Practice Location

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