Provider Demographics
NPI:1609852359
Name:WIEGEL, BRIAN J (MD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:J
Last Name:WIEGEL
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 1:5901 TECHNOLOGY CENTER DR
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46278-6013
Mailing Address - Country:US
Mailing Address - Phone:317-328-5050
Mailing Address - Fax:317-715-9965
Practice Address - Street 1:5901 TECHNOLOGY CENTER DR
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46278-6013
Practice Address - Country:US
Practice Address - Phone:317-328-5050
Practice Address - Fax:317-715-9965
Is Sole Proprietor?:No
Enumeration Date:2005-12-15
Last Update Date:2009-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01040536A2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000082131OtherANTHEM-351158723
IN200035270Medicaid
INQ0084960OtherCMOSHO351158723&352047427
IN059333OtherHEALTH ALLIANCE-351158723
IN000000492370OtherANTHEM 203778927
IN002095OtherSIHO-351158723
IN300100874OtherRR MEDICARE-351158723
IN200035270Medicaid
INF46998Medicare UPIN