Individual
DR. TODD M WIEDELL
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
O.D.
Contact information
Practice address
30960 GOVERNMENT DR, PEQUOT LAKES, MN 56472-1003
(218) 568-5555
(218) 568-8904
Mailing address
PO BOX 176, PEQUOT LAKES, MN 56472-0176
(218) 568-5555
(218) 568-8904
Taxonomy
Speciality
Code
Description
License number
State
152W00000X
Optometrist
Primary
2945
MN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
176684800
—
MN
01
—
2202446
MEDICA
MN
01
—
314L2WI
BLUE CROSS & BLUE SHIELD
MN
Enumeration date
05/26/2006
Last updated
01/21/2019
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