Healthcare Provider Details

I. General information

NPI: 1114911823
Provider Name (Legal Business Name): SAMUEL M WESONGA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: SAM WESONGA MD

II. Dates (important events)

Enumeration Date: 09/08/2005
Last Update Date: 04/14/2021
Certification Date: 04/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8001 T W ALEXANDER DR STE 216
RALEIGH NC
27617-4884
US

IV. Provider business mailing address

2920 HIGHWOODS BLVD
RALEIGH NC
27604-0010
US

V. Phone/Fax

Practice location:
  • Phone: 919-350-0953
  • Fax: 193-509-8189
Mailing address:
  • Phone: 877-498-4490
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number93-00369
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number9300369
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: