Provider Demographics
NPI:1619974243
Name:WIEGERING, CARLOS A (MD)
Entity Type:Individual
Prefix:DR
First Name:CARLOS
Middle Name:A
Last Name:WIEGERING
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 1:200 HOSPITAL DR
Mailing Address - Street 2:SUITE 3
Mailing Address - City:TYRONE
Mailing Address - State:PA
Mailing Address - Zip Code:16686-1825
Mailing Address - Country:US
Mailing Address - Phone:814-684-4472
Mailing Address - Fax:814-684-4780
Practice Address - Street 1:200 HOSPITAL DR
Practice Address - Street 2:SUITE 3
Practice Address - City:TYRONE
Practice Address - State:PA
Practice Address - Zip Code:16686-1825
Practice Address - Country:US
Practice Address - Phone:814-684-4472
Practice Address - Fax:814-684-4780
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-28
Last Update Date:2010-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD019247E208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0005918710002Medicaid
PA441021880OtherRR MEDICARE
PA0005918710002Medicaid
PA037272Medicare ID - Type Unspecified