Provider Demographics
NPI:1134196025
Name:WECKMANN, MICHELLE THERESE (MD)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:THERESE
Last Name:WECKMANN
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 1:200 HAWKINS DR
Mailing Address - Street 2:
Mailing Address - City:IOWA CITY
Mailing Address - State:IA
Mailing Address - Zip Code:52242-1009
Mailing Address - Country:US
Mailing Address - Phone:319-353-6314
Mailing Address - Fax:319-353-7788
Practice Address - Street 1:200 HAWKINS DR
Practice Address - Street 2:
Practice Address - City:IOWA CITY
Practice Address - State:IA
Practice Address - Zip Code:52242-1009
Practice Address - Country:US
Practice Address - Phone:319-353-6314
Practice Address - Fax:319-353-7788
Is Sole Proprietor?:No
Enumeration Date:2006-03-01
Last Update Date:2009-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA34940207Q00000X, 2084P0800X, 207RH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA55727OtherWELLMARK BCBS
IA2433748Medicaid
IAP00255819Medicare PIN
IA2433748Medicaid
I02060Medicare UPIN