Provider Demographics
NPI:1699706317
Name:WEISCHEDEL, GARRY RICHARD (MD)
Entity type:Individual
Prefix:
First Name:GARRY
Middle Name:RICHARD
Last Name:WEISCHEDEL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 WINDRIDGE ROAD
Mailing Address - Street 2:
Mailing Address - City:ESSEX JUNCTION
Mailing Address - State:VT
Mailing Address - Zip Code:05452
Mailing Address - Country:US
Mailing Address - Phone:802-879-6971
Mailing Address - Fax:
Practice Address - Street 1:1775 WILLISTON ROAD
Practice Address - Street 2:
Practice Address - City:SOUTH BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05403
Practice Address - Country:US
Practice Address - Phone:802-847-8500
Practice Address - Fax:802-847-6140
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0420009937207Q00000X
WI44142207Q00000X
MN44498207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34170200Medicaid
VTOVN2084Medicaid
VTVN2084Medicare ID - Type Unspecified
VTOVN2084Medicaid