1790721132 NPI number — GEOFFREY PAUL WIEDEMAN JR. M.D.

Table of content: GEOFFREY PAUL WIEDEMAN JR. M.D. (NPI 1790721132)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790721132 NPI number — GEOFFREY PAUL WIEDEMAN JR. M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WIEDEMAN
Provider First Name:
GEOFFREY
Provider Middle Name:
PAUL
Provider Name Prefix Text:
Provider Name Suffix Text:
JR.
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1790721132
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/09/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1201 ALHAMBRA BLVD
Provider Second Line Business Mailing Address:
410
Provider Business Mailing Address City Name:
SACRAMENTO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95816-5243
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
916-457-4263
Provider Business Mailing Address Fax Number:
916-731-7809

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1201 ALHAMBRA BLVD
Provider Second Line Business Practice Location Address:
410
Provider Business Practice Location Address City Name:
SACRAMENTO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95816-5243
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
916-457-4263
Provider Business Practice Location Address Fax Number:
916-731-7809
Provider Enumeration Date:
06/22/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  G30750 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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