MEDICARE: LISA M WIEDEL MD

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	207V00000X	Obstetrics & Gynecology Physician	21690	OK
2	207V00000X	Obstetrics & Gynecology Physician	ME110534	FL

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	:	1831166966
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA M WIEDEL MD

Provider Business Mailing Address
First Line	:	450 STATE ROAD 13
Second Line	:	STE 106-128
City	:	SAINT JOHNS
State	:	FL
Zip	:	32259-3860
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	450 STATE ROAD 13
Second Line	:	STE 106-128
City	:	SAINT JOHNS
State	:	FL
Zip	:	32259-3860
Country	:	US
Telephone Number	:	904-616-8410
Fax Number	:

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

Provider Enumeration Date	:	03/08/2006
Last Update Date	:	03/07/2013

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