Provider Demographics
NPI:1437117553
Name:WEGMAN, THERESA MARIE (MD)
Entity Type:Individual
Prefix:DR
First Name:THERESA
Middle Name:MARIE
Last Name:WEGMAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 CARROW ST
Mailing Address - Street 2:
Mailing Address - City:ORCHARD PARK
Mailing Address - State:NY
Mailing Address - Zip Code:14127-2604
Mailing Address - Country:US
Mailing Address - Phone:716-662-3443
Mailing Address - Fax:716-972-0374
Practice Address - Street 1:24 CARROW ST
Practice Address - Street 2:
Practice Address - City:ORCHARD PARK
Practice Address - State:NY
Practice Address - Zip Code:14127-2604
Practice Address - Country:US
Practice Address - Phone:716-662-3443
Practice Address - Fax:716-972-0374
Is Sole Proprietor?:No
Enumeration Date:2006-05-01
Last Update Date:2008-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2042332080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01924689Medicaid
NY00020530902OtherUNIVERA HEALTHCARE)
NY000525566002OtherBLUE CROS/BLUE SHEILD (HEALTH NOW)
NY1210624OtherINDEPENDENT HEALTH ASSOCIATION