Provider Demographics
NPI:1992806392
Name:WIEDER, NEAL (DC)
Entity type:Individual
Prefix:DR
First Name:NEAL
Middle Name:
Last Name:WIEDER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1045 PRIMERA BLVD STE 1017
Mailing Address - Street 2:
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746-2178
Mailing Address - Country:US
Mailing Address - Phone:407-682-4454
Mailing Address - Fax:407-682-3805
Practice Address - Street 1:1045 PRIMERA BLVD STE 1017
Practice Address - Street 2:
Practice Address - City:LAKE MARY
Practice Address - State:FL
Practice Address - Zip Code:32746-2178
Practice Address - Country:US
Practice Address - Phone:407-682-4454
Practice Address - Fax:407-682-3805
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-26
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH3063133N00000X, 202C00000X, 111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No133N00000XDietary & Nutritional Service ProvidersNutritionist
No202C00000XAllopathic & Osteopathic PhysiciansIndependent Medical Examiner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL88322AMedicare PIN
FLT84680Medicare UPIN