Healthcare Provider Details

I. General information

NPI: 1477247880
Provider Name (Legal Business Name): DR. DOMONICK JAY WEGESIN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/07/2023
Last Update Date: 06/07/2023
Certification Date: 06/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1930 MARKET ST
SAN FRANCISCO CA
94102-6228
US

IV. Provider business mailing address

12 SHETLAND CT
OAKLAND CA
94605-5632
US

V. Phone/Fax

Practice location:
  • Phone: 415-476-3902
  • Fax:
Mailing address:
  • Phone: 510-219-1851
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: