MEDICARE: LEAH WIEDEMAMN O.D.

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	152W00000X	Optometrist	2014021357	MO

General Provider Information

NPI Number	:	1073910386
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LEAH WIEDEMAMN O.D.

Provider Business Mailing Address
First Line	:	716 N HALIFAX AVE APT 13
Second Line	:
City	:	DAYTONA BEACH
State	:	FL
Zip	:	32118-3856
Country	:	US
Telephone Number	:	314-583-0324
Fax Number	:

Provider Business Practice Location Address
First Line	:	716 N HALIFAX AVE APT 9
Second Line	:
City	:	DAYTONA BEACH
State	:	FL
Zip	:	32118-3852
Country	:	US
Telephone Number	:	314-583-0324
Fax Number	:

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

Provider Enumeration Date	:	12/02/2014
Last Update Date	:	06/08/2015

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