Basic Information
| Provider Information | |||||||||
| NPI: | 1023000304 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WEDEMEYER | ||||||||
| FirstName: | ELISSA | ||||||||
| MiddleName: | R. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6026 HIGHWAY 6 | ||||||||
| Address2: | |||||||||
| City: | MISSOURI CITY | ||||||||
| State: | TX | ||||||||
| PostalCode: | 774594163 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2814992600 | ||||||||
| FaxNumber: | 2814996556 | ||||||||
| Practice Location | |||||||||
| Address1: | 6026 HIGHWAY 6 | ||||||||
| Address2: | |||||||||
| City: | MISSOURI CITY | ||||||||
| State: | TX | ||||||||
| PostalCode: | 774594163 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2814992600 | ||||||||
| FaxNumber: | 2814996556 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/22/2005 | ||||||||
| LastUpdateDate: | 10/08/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | TX4167TG | TX | Y | Eye and Vision Services Providers | Optometrist | 174400000X | TX4167TG | TX | N | Other Service Providers | Specialist |
No ID Information.