Provider Demographics
NPI:1699931139
Name:WEDIG, BRENDA S (OD)
Entity type:Individual
Prefix:
First Name:BRENDA
Middle Name:S
Last Name:WEDIG
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2104 STATE ROAD 16
Mailing Address - Street 2:
Mailing Address - City:LA CROSSE
Mailing Address - State:WI
Mailing Address - Zip Code:54601-3046
Mailing Address - Country:US
Mailing Address - Phone:608-782-7127
Mailing Address - Fax:
Practice Address - Street 1:2104 STATE ROAD 16
Practice Address - Street 2:
Practice Address - City:LA CROSSE
Practice Address - State:WI
Practice Address - Zip Code:54601-3046
Practice Address - Country:US
Practice Address - Phone:608-782-7127
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-04
Last Update Date:2009-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3192152W00000X
WIWI 3116-035152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38645900Medicaid