Provider Demographics
NPI:1265459838
Name:WECKENBROCK, GREGORY P (MD)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:P
Last Name:WECKENBROCK
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:830 THOMAS MORE PKWY
Mailing Address - Street 2:STE 203
Mailing Address - City:EDGEWOOD
Mailing Address - State:KY
Mailing Address - Zip Code:41017-5102
Mailing Address - Country:US
Mailing Address - Phone:859-341-5757
Mailing Address - Fax:859-331-4757
Practice Address - Street 1:830 THOMAS MORE PKWY
Practice Address - Street 2:STE 203
Practice Address - City:EDGEWOOD
Practice Address - State:KY
Practice Address - Zip Code:41017-5102
Practice Address - Country:US
Practice Address - Phone:859-341-5757
Practice Address - Fax:859-331-4757
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2007-09-21
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Provider Licenses
StateLicense IDTaxonomies
KY23567207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0638582Medicaid
KY64235674Medicaid
KYB28511Medicare UPIN
KY0970101Medicare PIN