Provider Demographics
NPI:1053357293
Name:WEIDE, JEFFREY A (DC)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:A
Last Name:WEIDE
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 1:7280 S 13TH ST STE 103
Mailing Address - Street 2:
Mailing Address - City:OAK CREEK
Mailing Address - State:WI
Mailing Address - Zip Code:53154-1831
Mailing Address - Country:US
Mailing Address - Phone:414-768-9000
Mailing Address - Fax:414-768-9004
Practice Address - Street 1:7280 S 13TH ST STE103
Practice Address - Street 2:
Practice Address - City:OAK CREEK
Practice Address - State:WI
Practice Address - Zip Code:53154-1831
Practice Address - Country:US
Practice Address - Phone:414-768-9000
Practice Address - Fax:414-768-9004
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-22
Last Update Date:2010-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1599-012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38780400Medicaid
WIT63627Medicare UPIN
WI000035322Medicare ID - Type Unspecified