Healthcare Provider Details

I. General information

NPI: 1679979249
Provider Name (Legal Business Name): DAVID WIEGAND OP/L
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/10/2014
Last Update Date: 11/10/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 SADDLE DR
NASHVILLE TN
37221-1905
US

IV. Provider business mailing address

501 SADDLE DR
NASHVILLE TN
37221-1905
US

V. Phone/Fax

Practice location:
  • Phone: 615-891-0104
  • Fax:
Mailing address:
  • Phone: 615-891-0104
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code222Z00000X
TaxonomyOrthotist
License NumberORT045
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code224P00000X
TaxonomyProsthetist
License NumberPRO034
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: