Provider Demographics
NPI:1912083155
Name:WEGHORST, THADDEUS R (MD)
Entity Type:Individual
Prefix:DR
First Name:THADDEUS
Middle Name:R
Last Name:WEGHORST
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:6920 POINTE INVERNESS WAY STE 200
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-7934
Mailing Address - Country:US
Mailing Address - Phone:260-927-0035
Mailing Address - Fax:260-927-0036
Practice Address - Street 1:510 SMALTZ WAY
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:IN
Practice Address - Zip Code:46706-0612
Practice Address - Country:US
Practice Address - Phone:260-927-0035
Practice Address - Fax:260-927-0036
Is Sole Proprietor?:No
Enumeration Date:2006-10-31
Last Update Date:2024-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01057752A207VX0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200427390Medicaid
IN200427390Medicaid
IN225540BMedicare ID - Type Unspecified
IN200427390Medicaid