MEDICARE: DIETER TETATAH WEFUAN M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician	2013-02459	NC
2	207R00000X	Internal Medicine Physician	2013-02459	NC

General Provider Information

NPI Number	:	1073834917
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DIETER TETATAH WEFUAN M.D.

Provider Business Mailing Address
First Line	:	1444 S 17TH ST
Second Line	:
City	:	WILMINGTON
State	:	NC
Zip	:	28401-6436
Country	:	US
Telephone Number	:	910-793-4311
Fax Number	:	910-793-4322

Provider Business Practice Location Address
First Line	:	401 N MAIN ST
Second Line	:
City	:	KENANSVILLE
State	:	NC
Zip	:	28349-8801
Country	:	US
Telephone Number	:	252-214-8598
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/15/2010
Last Update Date	:	04/24/2019

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