Healthcare Provider Details

I. General information

NPI: 1568512143
Provider Name (Legal Business Name): THOMAS JOSEPH WEGMAN PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/12/2007
Last Update Date: 07/15/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5190 GOVERNOR DR STE 104
SAN DIEGO CA
92122-2848
US

IV. Provider business mailing address

5190 GOVERNOR DR STE 104
SAN DIEGO CA
92122-2848
US

V. Phone/Fax

Practice location:
  • Phone: 858-455-5252
  • Fax: 858-455-5556
Mailing address:
  • Phone: 858-455-5252
  • Fax: 858-455-5556

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License NumberPSY4228
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY4228
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: