Provider Demographics
NPI:1508877952
Name:WECKEL, BRYAN MONTY (MD)
Entity Type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:MONTY
Last Name:WECKEL
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 1266
Mailing Address - Street 2:
Mailing Address - City:BURGAW
Mailing Address - State:NC
Mailing Address - Zip Code:28425-1266
Mailing Address - Country:US
Mailing Address - Phone:910-259-1718
Mailing Address - Fax:910-259-9929
Practice Address - Street 1:310 S BENNETT ST
Practice Address - Street 2:
Practice Address - City:BURGAW
Practice Address - State:NC
Practice Address - Zip Code:28425-5048
Practice Address - Country:US
Practice Address - Phone:910-259-1718
Practice Address - Fax:910-259-9929
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9901353207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89130TEMedicaid
NCH45220Medicare UPIN
NC89130TEMedicaid