Provider Demographics
NPI:1962461210
Name:WEIGERT, JEAN MIRIAM (MD)
Entity Type:Individual
Prefix:
First Name:JEAN
Middle Name:MIRIAM
Last Name:WEIGERT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 FOUNDERS PLZ
Mailing Address - Street 2:SUITE 400
Mailing Address - City:EAST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06108-3212
Mailing Address - Country:US
Mailing Address - Phone:860-289-3375
Mailing Address - Fax:860-783-5733
Practice Address - Street 1:85 SEYMOUR ST STE 200
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06106-5509
Practice Address - Country:US
Practice Address - Phone:860-246-6589
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0261262085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT300117750OtherRAILROAD MEDICARE
CT010026126CT03OtherANTHEM BC/BS
CT010026126CT06OtherANTHEM BC/BS
CT010026126CT07OtherANTHEM BC/BS
CT300063380OtherRAILROAD MEDICARE
CT1261263Medicaid
CT300023206OtherRAILROAD MEDICARE
CT010026126CT04OtherANTHEM BC/BS
CT010026126CT12OtherANTHEM BC/BS
CT010026126CT14OtherANTHEM BC/BS
CT300023203OtherRAILROAD MEDICARE
CT010026126CT07OtherANTHEM BC/BS
CT300117750OtherRAILROAD MEDICARE
CT300000949Medicare PIN
CT300000942Medicare PIN
CT010026126CT12OtherANTHEM BC/BS
CT1261263Medicaid