Provider Demographics
NPI:1417940800
Name:WIEGERING, CARLOS MARTIN (DC)
Entity Type:Individual
Prefix:
First Name:CARLOS
Middle Name:MARTIN
Last Name:WIEGERING
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:502 LOGAN BLVD
Mailing Address - Street 2:
Mailing Address - City:ALTOONA
Mailing Address - State:PA
Mailing Address - Zip Code:16602-4104
Mailing Address - Country:US
Mailing Address - Phone:814-944-3536
Mailing Address - Fax:814-941-7660
Practice Address - Street 1:502 LOGAN BLVD
Practice Address - Street 2:
Practice Address - City:ALTOONA
Practice Address - State:PA
Practice Address - Zip Code:16602-4104
Practice Address - Country:US
Practice Address - Phone:814-944-3536
Practice Address - Fax:814-941-7660
Is Sole Proprietor?:No
Enumeration Date:2005-08-31
Last Update Date:2009-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC008692111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0019480800001Medicaid
PA0019480800001Medicaid
PA056960Medicare ID - Type Unspecified