Individual
LISA M WIEDEL
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
MD
Contact information
Practice address
450 STATE ROAD 13, STE 106-128, SAINT JOHNS, FL 32259-3860
(904) 616-8410
Mailing address
450 STATE ROAD 13, STE 106-128, SAINT JOHNS, FL 32259-3860
Taxonomy
Speciality
Code
Description
License number
State
207V00000X
Obstetrics & Gynecology Physician
21690
OK
207V00000X
Obstetrics & Gynecology Physician
Primary
ME110534
FL
Other
Enumeration date
03/08/2006
Last updated
03/07/2013
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