MEDICARE: DERRICK WEGNER

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	225X00000X	Occupational Therapist	OT23591	CA

General Provider Information

NPI Number	:	1285313486
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DERRICK WEGNER

Provider Business Mailing Address
First Line	:	3 FORTUNE RD W APT 3G
Second Line	:
City	:	MIDDLETOWN
State	:	NY
Zip	:	10941-1685
Country	:	US
Telephone Number	:	845-421-2352
Fax Number	:

Provider Business Practice Location Address
First Line	:	DIABLO VALLEY POST ACUTE
Second Line	:	3806 CLAYTON ROAD
City	:	CONCORD
State	:	CA
Zip	:	94521
Country	:	US
Telephone Number	:	971-206-5140
Fax Number	:

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

Provider Enumeration Date	:	07/14/2023
Last Update Date	:	07/14/2023

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