Provider Demographics
NPI:1194029116
Name:ELISSA R WEDEMEYER
Entity type:Organization
Organization Name:ELISSA R WEDEMEYER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ELISSA
Authorized Official - Middle Name:R
Authorized Official - Last Name:WEDEMEYER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:281-499-2600
Mailing Address - Street 1:6026 HIGHWAY 6
Mailing Address - Street 2:
Mailing Address - City:MISSOURI CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77459-4163
Mailing Address - Country:US
Mailing Address - Phone:281-499-2600
Mailing Address - Fax:281-499-6556
Practice Address - Street 1:6026 HIGHWAY 6
Practice Address - Street 2:
Practice Address - City:MISSOURI CITY
Practice Address - State:TX
Practice Address - Zip Code:77459-4163
Practice Address - Country:US
Practice Address - Phone:281-499-2600
Practice Address - Fax:281-499-6556
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-05
Last Update Date:2011-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX4167TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXU05302Medicare UPIN
TX00E44NMedicare PIN