Basic Information
| Provider Information | |||||||||
| NPI: | 1679190755 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WEIDOW | ||||||||
| FirstName: | NICOLE | ||||||||
| MiddleName: | CATHERINE | ||||||||
| NamePrefix: | |||||||||
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| Credential: | DO | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MICHEL | ||||||||
| OtherFirstName: | NICOLE | ||||||||
| OtherMiddleName: | CATHERINE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | DO | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 750 MORPHY AVE | ||||||||
| Address2: | |||||||||
| City: | FAIRHOPE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 365321812 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 2451 UNIVERSITY HOSPITAL DR RM 714 | ||||||||
| Address2: | |||||||||
| City: | MOBILE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 366172300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2514343915 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/06/2020 | ||||||||
| LastUpdateDate: | 03/30/2021 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/30/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | AL | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 208000000X | 1679190755 | AL | Y | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.