Provider Demographics
NPI:1467566398
Name:WIEGAND, TIMOTHY J (MD)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:J
Last Name:WIEGAND
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 1:601 ELMWOOD AVE
Mailing Address - Street 2:BOX 655
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14642-8655
Mailing Address - Country:US
Mailing Address - Phone:585-275-9555
Mailing Address - Fax:
Practice Address - Street 1:601 ELMWOOD AVE
Practice Address - Street 2:BOX 655
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14642-8655
Practice Address - Country:US
Practice Address - Phone:585-275-9555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-18
Last Update Date:2023-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME017860207PT0002X, 207R00000X, 208M00000X
CAA88509207R00000X
NY258256207PT0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PT0002XAllopathic & Osteopathic PhysiciansEmergency MedicineMedical Toxicology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30207895Medicaid
ME432977599Medicaid
NY03257283Medicaid
ME000752801Medicare PIN
NYJ400027347Medicare PIN
NYJ400027481Medicare PIN
NYJ400037888Medicare PIN
MEP00658301Medicare PIN
CAI26039Medicare UPIN
NY03257283Medicaid