Provider Demographics
NPI:1114911823
Name:WESONGA, SAMUEL M (MD)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:M
Last Name:WESONGA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:SAM
Other - Middle Name:
Other - Last Name:WESONGA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:2920 HIGHWOODS BLVD
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27604-0010
Mailing Address - Country:US
Mailing Address - Phone:877-498-4490
Mailing Address - Fax:
Practice Address - Street 1:8001 T W ALEXANDER DR STE 216
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27617-4884
Practice Address - Country:US
Practice Address - Phone:919-350-0953
Practice Address - Fax:193-509-8189
Is Sole Proprietor?:No
Enumeration Date:2005-09-08
Last Update Date:2021-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC93-00369207Q00000X
NC9300369207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC80084731OtherRAILROAD MEDICARE
NC8986588Medicaid
NC59381OtherMEDCOST
NC86588OtherBCBSNC
NC5497949OtherCIGNA HEALTHCARE
NC80084731OtherRAILROAD MEDICARE
NC2190505CMedicare PIN