MEDICARE: DR. JEFFREY RYAN WIEDRICH 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	2664	CO

General Provider Information

NPI Number	:	1225287444
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JEFFREY RYAN WIEDRICH O.D.

Provider Business Mailing Address
First Line	:	1100 MAIN ST
Second Line	:
City	:	FORT MORGAN
State	:	CO
Zip	:	80701-2036
Country	:	US
Telephone Number	:	806-336-7105
Fax Number	:

Provider Business Practice Location Address
First Line	:	1100 MAIN ST
Second Line	:
City	:	FORT MORGAN
State	:	CO
Zip	:	80701-2036
Country	:	US
Telephone Number	:	806-336-7105
Fax Number	:

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

Provider Enumeration Date	:	09/11/2008
Last Update Date	:	11/30/2017

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