Provider Demographics
NPI:1881861839
Name:WIEGMAN, KATHERINE ELEANOR (MD)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:ELEANOR
Last Name:WIEGMAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KATHERINE
Other - Middle Name:ELEANOR
Other - Last Name:HORSLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:643 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PALMETTO
Mailing Address - State:GA
Mailing Address - Zip Code:30268-1138
Mailing Address - Country:US
Mailing Address - Phone:404-929-8824
Mailing Address - Fax:404-929-9769
Practice Address - Street 1:48 MAIN ST STE 3A
Practice Address - Street 2:
Practice Address - City:SENOIA
Practice Address - State:GA
Practice Address - Zip Code:30276-1895
Practice Address - Country:US
Practice Address - Phone:678-723-0400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-09
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA67629207Q00000X, 207R00000X
NE29748207Q00000X
GA067629207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003124917CMedicaid
NE1881861839Medicaid
GA003124917DMedicaid