Provider Demographics
NPI:1497910061
Name:WECKESSER, STEPHANIE MARIE (MD)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:MARIE
Last Name:WECKESSER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:MARIE
Other - Last Name:GARDYZA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:745 HASKINS RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:BOWLING GREEN
Mailing Address - State:OH
Mailing Address - Zip Code:43402-1600
Mailing Address - Country:US
Mailing Address - Phone:419-353-7069
Mailing Address - Fax:419-353-7076
Practice Address - Street 1:970 W WOOSTER ST
Practice Address - Street 2:SUITE 130
Practice Address - City:BOWLING GREEN
Practice Address - State:OH
Practice Address - Zip Code:43402-2643
Practice Address - Country:US
Practice Address - Phone:419-352-6890
Practice Address - Fax:419-353-2415
Is Sole Proprietor?:No
Enumeration Date:2008-07-23
Last Update Date:2016-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35097856208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0061307Medicaid