Provider Demographics
NPI:1508852310
Name:WIEGMAN, RALPH THANE (MD)
Entity Type:Individual
Prefix:
First Name:RALPH
Middle Name:THANE
Last Name:WIEGMAN
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 1:643 S GREAT SOUTHWEST PKWY
Mailing Address - Street 2:STE 102
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75051-1056
Mailing Address - Country:US
Mailing Address - Phone:972-647-0994
Mailing Address - Fax:972-647-0521
Practice Address - Street 1:643 S GREAT SOUTHWEST PKWY
Practice Address - Street 2:STE 102
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75051-1056
Practice Address - Country:US
Practice Address - Phone:972-647-0994
Practice Address - Fax:972-647-0521
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF2113207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXHK66Medicare ID - Type Unspecified
B27558Medicare UPIN