Provider Demographics
NPI:1285646695
Name:WIEGARTZ, PAMELA
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:
Last Name:WIEGARTZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:221 LONGWOOD AVE FL 4
Mailing Address - Street 2:PSYCHIATRY
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02115-5804
Mailing Address - Country:US
Mailing Address - Phone:617-429-8584
Mailing Address - Fax:
Practice Address - Street 1:221 LONGWOOD AVE FL 4
Practice Address - Street 2:PSYCHIATRY
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02115-5804
Practice Address - Country:US
Practice Address - Phone:617-732-6766
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-13
Last Update Date:2014-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0710061142084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
594560Medicare PIN