Provider Demographics
NPI:1376432435
Name:WIEDELL, MATTHEW T (OD)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:T
Last Name:WIEDELL
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 3RD AVE NE
Mailing Address - Street 2:
Mailing Address - City:CROSBY
Mailing Address - State:MN
Mailing Address - Zip Code:56441-1665
Mailing Address - Country:US
Mailing Address - Phone:218-546-5108
Mailing Address - Fax:218-546-5736
Practice Address - Street 1:1 3RD AVE NE
Practice Address - Street 2:
Practice Address - City:CROSBY
Practice Address - State:MN
Practice Address - Zip Code:56441-1665
Practice Address - Country:US
Practice Address - Phone:218-546-5108
Practice Address - Fax:218-546-5736
Is Sole Proprietor?:No
Enumeration Date:2025-07-01
Last Update Date:2025-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4018152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist