Individual
DR. LEE ROY WIEDERHOLD III
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD, PHD
Contact information
Practice address
301 UNIVERSITY BLVD, GALVESTON, TX 77555-0462
(409) 772-2531
(409) 772-1814
Mailing address
301 UNIVERSITY BLVD, GALVESTON, TX 77555-5302
(409) 772-2222
Taxonomy
Speciality
Code
Description
License number
State
2085R0001X
Radiation Oncology Physician
Primary
M5976
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
213444702
—
TX
01
—
213444703
MEDICAID CSHCN
TX
01
—
3847415682
MYUTMB 3847415682-COMMERCIAL NUMBER
—
Enumeration date
06/14/2007
Last updated
01/29/2019
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