Provider Demographics
NPI:1033103718
Name:WIEGAND, LAURA GREENE (MD)
Entity Type:Individual
Prefix:DR
First Name:LAURA
Middle Name:GREENE
Last Name:WIEGAND
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1983 CROMPOND RD
Mailing Address - Street 2:
Mailing Address - City:CORTLANDT MANOR
Mailing Address - State:NY
Mailing Address - Zip Code:10567-4121
Mailing Address - Country:US
Mailing Address - Phone:914-736-1100
Mailing Address - Fax:714-736-2071
Practice Address - Street 1:1983 CROMPOND RD
Practice Address - Street 2:
Practice Address - City:CORTLANDT MANOR
Practice Address - State:NY
Practice Address - Zip Code:10567-4121
Practice Address - Country:US
Practice Address - Phone:914-736-1100
Practice Address - Fax:714-736-2071
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY164398207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01559351Medicaid
NY62F381Medicare ID - Type Unspecified
NY01559351Medicaid