Provider Demographics
NPI:1568512143
Name:WEGMAN, THOMAS JOSEPH (PHD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:JOSEPH
Last Name:WEGMAN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5190 GOVERNOR DR STE 104
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92122-2848
Mailing Address - Country:US
Mailing Address - Phone:858-455-5252
Mailing Address - Fax:858-455-5556
Practice Address - Street 1:5190 GOVERNOR DR STE 104
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92122-2848
Practice Address - Country:US
Practice Address - Phone:858-455-5252
Practice Address - Fax:858-455-5556
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-12
Last Update Date:2013-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY4228103G00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACP4228Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER