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DR. TODD M WIEDELL O.D.

>> Optometrist >> Eye and Vision Services Providers

Registrant NPI Number: 1295781425

Individual Registrant:
DR. TODD M WIEDELL O.D.
Gender: M
Sole Proprietor

Location and contact information for practice:
30960 GOVERNMENT DR  PEQUOT LAKES, MN 56472-1003 US
Tel: 218-568-5555  Fax: 218-568-8904

Contact information for business:
PO BOX 176  PEQUOT LAKES, MN 56472-0176 US
Tel: 218-568-5555  Fax: 218-568-8904

Registration Information:
NPI: 1295781425
Entity Type: Individual

Specialty information:

PrimaryCodeCategory/DescriptionStateLicense Number
Y152W00000XEye and Vision Services Providers
Optometrist
MN2945

Legacy codes, insurance codes and state license numbers:

IssuerNumberStateType
BLUE CROSS & BLUE SHIELD314L2WIMN01
MEDICA2202446MN01
176684800MN05




HEALTH CARE JOBS MN - Page 1



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