1083893101 NPI number — DR. LUCAS ROSS WIEGAND MD

Table of content: MR. MARK P MCKNIGHT IDC (NPI 1639131444)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083893101 NPI number — DR. LUCAS ROSS WIEGAND MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WIEGAND
Provider First Name:
LUCAS
Provider Middle Name:
ROSS
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1083893101
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/18/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
303 E PAR ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ORLANDO
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32804-4003
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
877-876-3627
Provider Business Mailing Address Fax Number:
321-843-4101

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
303 E PAR ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ORLANDO
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32804-4003
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
877-876-3627
Provider Business Practice Location Address Fax Number:
321-843-4101
Provider Enumeration Date:
10/25/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208800000X , with the licence number:  24854 , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208800000X , with the licence number: 2011010512 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208800000X , with the licence number: ME103855 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 3810023512 . This is a "MEDICAID" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: WV1425A . This is a "MEDICARE PTAN" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: 014458200 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 14JR6 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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