Todd M. Wiedel, O.D., PA

Primary specialty

OptometristTaxonomy code 152W00000X

Legal business name

TODD M. WIEDEL, O.D., PA

Practice address

30960 Government Dr
Pequot Lakes, MN 56472-1003

Phone

(218) 568-5555

Fax

(218) 568-8904

NPI assigned

Dec 18, 2009

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Dr. Todd M Wiedell, ODNPI 1295781425

Title

Director of Corporation

Phone

(218) 568-5555

Specialties & licenses 2

Addresses

Other identifiers 3

Other names 2

• Crosslake Eye Center Doing business as
• Pequot Eye Center Doing business as

Medicare fee-for-service enrollment

Enrolled in MN2 enrollments

Enrollment records 2

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

Medicare medical equipment & supply locations

Locations

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

• Todd M Wiedell, O.D.

  • Optometrist
  • Pequot Lakes, MN
  • NPI 1295781425
  Medicare reassignment Authorized official

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1261094400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1570665600000",
    "number": "1831428903",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 176",
            "city": "PEQUOT LAKES",
            "state": "MN",
            "postal_code": "564720176",
            "telephone_number": "218-568-5555",
            "fax_number": "218-568-8904"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "30960 GOVERNMENT DR",
            "city": "PEQUOT LAKES",
            "state": "MN",
            "postal_code": "564721003",
            "telephone_number": "218-568-5555",
            "fax_number": "218-568-8904"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "13833 Riverwood Ln",
            "address_purpose": "LOCATION",
            "city": "Crosslake",
            "state": "MN",
            "postal_code": "564422823",
            "country_code": "US",
            "telephone_number": "218-692-4700",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "organization_name": "TODD M. WIEDEL, O.D., PA",
        "organizational_subpart": "NO",
        "enumeration_date": "2009-12-18",
        "last_updated": "2019-10-10",
        "status": "A",
        "authorized_official_last_name": "WIEDELL",
        "authorized_official_first_name": "TODD",
        "authorized_official_middle_name": "M",
        "authorized_official_title_or_position": "DIRECTOR OF CORPORATION",
        "authorized_official_telephone_number": "218-568-5555",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "OD"
    },
    "taxonomies": [
        {
            "code": "152W00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Optometrist",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "332H00000X",
            "taxonomy_group": "",
            "desc": "Eyewear Supplier",
            "state": "MN",
            "license": "2945",
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "176684800",
            "state": "MN"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BCBS",
            "identifier": "1BI74PE",
            "state": "MN"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICA",
            "identifier": "22-05547",
            "state": "MN"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Crosslake Eye Center",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Pequot Eye Center",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• Mark Thomas Sherman, D.D.S.
• Kelly A Spray, CNP
• St. Joseph'S Medical Center
• Payden Strange
• Carrie Taylor, PT
• Todd M Wiedell, O.D.
• Violet Marie Wurtzberger, MS, LPCC, LADC

• Optometrist in Pequot Lakes, MN
• Providers in Pequot Lakes, MN by specialty
• Optometrist in Minnesota

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 10, 2019; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.