Provider Demographics
NPI:1083893101
Name:WIEGAND, LUCAS ROSS (MD)
Entity Type:Individual
Prefix:DR
First Name:LUCAS
Middle Name:ROSS
Last Name:WIEGAND
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:303 E PAR ST
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32804-4003
Mailing Address - Country:US
Mailing Address - Phone:877-876-3627
Mailing Address - Fax:321-843-4101
Practice Address - Street 1:303 E PAR ST
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32804-4003
Practice Address - Country:US
Practice Address - Phone:877-876-3627
Practice Address - Fax:321-843-4101
Is Sole Proprietor?:No
Enumeration Date:2007-10-25
Last Update Date:2023-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV24854208800000X
MO2011010512208800000X
FLME103855208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810023512OtherMEDICAID
WVWV1425AOtherMEDICARE PTAN
FL014458200Medicaid
FL14JR6OtherBLUE CROSS BLUE SHIELD
WV3810023512OtherMEDICAID
FLP01488622Medicare PIN