Provider Demographics
NPI:1316908882
Name:WIEBE, EDWARD LOUIS (DPM)
Entity type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:LOUIS
Last Name:WIEBE
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 W COLUMBUS AVE
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-3202
Mailing Address - Country:US
Mailing Address - Phone:928-226-7555
Mailing Address - Fax:928-226-0014
Practice Address - Street 1:8 W COLUMBUS AVE
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-3202
Practice Address - Country:US
Practice Address - Phone:928-774-4825
Practice Address - Fax:928-779-1008
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-31
Last Update Date:2011-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ0076213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ700270-001Medicaid
AZAZ0065350OtherBC/BS ID#
AZAZ0065350OtherBC/BS ID#
AZT42264Medicare UPIN
AZ0353890001Medicare NSC