Provider Demographics
NPI:1396748703
Name:WIEGAND, THOMAS JOSEPH (OD)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:JOSEPH
Last Name:WIEGAND
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 549
Mailing Address - Street 2:
Mailing Address - City:WABASH
Mailing Address - State:IN
Mailing Address - Zip Code:46992-0549
Mailing Address - Country:US
Mailing Address - Phone:260-569-9550
Mailing Address - Fax:260-569-0760
Practice Address - Street 1:712 CAMERON WOODS DR
Practice Address - Street 2:
Practice Address - City:ANGOLA
Practice Address - State:IN
Practice Address - Zip Code:46703
Practice Address - Country:US
Practice Address - Phone:260-668-3937
Practice Address - Fax:260-668-3794
Is Sole Proprietor?:No
Enumeration Date:2005-05-31
Last Update Date:2018-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18001620152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000092387OtherANTHEM BCBS
IN100152890Medicaid
IN160450024Medicare PIN
INM400074879Medicare PIN
IN000000092387OtherANTHEM BCBS
IN1180960001Medicare NSC
INP01121417Medicare PIN
INM400074900Medicare PIN
IN771660BMedicare PIN