Basic Information
Provider Information
NPI: 1194029116
EntityType: 2
ReplacementNPI:  
OrganizationName: ELISSA R WEDEMEYER
LastName:  
FirstName:  
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
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: 01/05/2011
LastUpdateDate: 01/05/2011
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode:  
AuthorizedOfficialLastName: WEDEMEYER
AuthorizedOfficialFirstName: ELISSA
AuthorizedOfficialMiddleName: R
AuthorizedOfficialTitleorPosition: OWNER
AuthorizedOfficialTelephone: 2814992600
IsSoleProprietor:  
IsOrganizationSubpart: N
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential: O.D.
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
152W00000X4167TGTXY193400000X SINGLE SPECIALTY GROUPEye and Vision Services ProvidersOptometrist 

No ID Information.


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