MEDICARE: DR. MARY COLLEEN WEIDMAN DPT

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	225100000X	Physical Therapist	6264	OK

General Provider Information

NPI Number	:	1235849852
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARY COLLEEN WEIDMAN DPT

Provider Business Mailing Address
First Line	:	11414 E 51ST ST STE E
Second Line	:
City	:	TULSA
State	:	OK
Zip	:	74146-5825
Country	:	US
Telephone Number	:	479-719-5045
Fax Number	:

Provider Business Practice Location Address
First Line	:	11414 E 51ST ST STE E
Second Line	:
City	:	TULSA
State	:	OK
Zip	:	74146-5825
Country	:	US
Telephone Number	:	479-719-5045
Fax Number	:

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

Provider Enumeration Date	:	12/05/2022
Last Update Date	:	12/05/2022

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