Provider Demographics
NPI:1306813910
Name:WEGERT, STEVEN J (MD)
Entity Type:Individual
Prefix:
First Name:STEVEN
Middle Name:J
Last Name:WEGERT
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:PO BOX 63300
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80962-3300
Mailing Address - Country:US
Mailing Address - Phone:719-578-1162
Mailing Address - Fax:719-578-1462
Practice Address - Street 1:1400 E BOULDER ST
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80909-5533
Practice Address - Country:US
Practice Address - Phone:719-365-5853
Practice Address - Fax:719-365-1048
Is Sole Proprietor?:No
Enumeration Date:2006-03-02
Last Update Date:2022-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.00342492085R0202X
CO342492085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO15574075Medicaid
COCO305121Medicare PIN
F75849Medicare UPIN
87060RMedicare ID - Type UnspecifiedSTRIC MEDICARE
COCOA103770Medicare PIN
COCOA108087Medicare PIN