Provider Demographics
NPI:1689104242
Name:WIEGING, ANDREW (MD)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:
Last Name:WIEGING
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 1:3534 BROOKLYN AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46809-1361
Mailing Address - Country:US
Mailing Address - Phone:260-478-5135
Mailing Address - Fax:260-478-5187
Practice Address - Street 1:3534 BROOKLYN AVE
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46809-1361
Practice Address - Country:US
Practice Address - Phone:260-478-5135
Practice Address - Fax:260-478-5187
Is Sole Proprietor?:No
Enumeration Date:2017-06-15
Last Update Date:2020-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN11019460A207Q00000X
IN01082630A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine