Provider Demographics
NPI:1548532757
Name:WIEDRICH, LILY
Entity type:Individual
Prefix:
First Name:LILY
Middle Name:
Last Name:WIEDRICH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1091 WIDGEON RD
Mailing Address - Street 2:
Mailing Address - City:WELLINGTON
Mailing Address - State:FL
Mailing Address - Zip Code:33414-5049
Mailing Address - Country:US
Mailing Address - Phone:561-798-3300
Mailing Address - Fax:
Practice Address - Street 1:12983 SOUTHERN BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:LOXAHATCHEE
Practice Address - State:FL
Practice Address - Zip Code:33470-9207
Practice Address - Country:US
Practice Address - Phone:561-798-3300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-02-02
Last Update Date:2013-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS11572208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL008571300Medicaid