MEDICARE: DR. NATHAN HENRY WIEDERHOLT 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	656	SD

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1447414461
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. NATHAN HENRY WIEDERHOLT O.D.

Provider Business Mailing Address
First Line	:	322 MOUNT RUSHMORE RD
Second Line	:	SUITE 120
City	:	CUSTER
State	:	SD
Zip	:	57730-1936
Country	:	US
Telephone Number	:	605-673-2716
Fax Number	:	605-673-2017

Provider Business Practice Location Address
First Line	:	322 MOUNT RUSHMORE RD
Second Line	:	SUITE 120
City	:	CUSTER
State	:	SD
Zip	:	57730-1936
Country	:	US
Telephone Number	:	605-673-2716
Fax Number	:	605-673-2017

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

Provider Enumeration Date	:	07/18/2008
Last Update Date	:	06/16/2010

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