MEDICARE: THOMAS JOSEPH WIEGAND O.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	152W00000X	Optometrist	18001620	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	000000092387	OTHER	IN	ANTHEM BCBS
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1396748703
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	THOMAS JOSEPH WIEGAND O.D.

Provider Business Mailing Address
First Line	:	PO BOX 549
Second Line	:
City	:	WABASH
State	:	IN
Zip	:	46992-0549
Country	:	US
Telephone Number	:	260-569-9550
Fax Number	:	260-569-0760

Provider Business Practice Location Address
First Line	:	712 CAMERON WOODS DR
Second Line	:
City	:	ANGOLA
State	:	IN
Zip	:	46703
Country	:	US
Telephone Number	:	260-668-3937
Fax Number	:	260-668-3794

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

Provider Enumeration Date	:	05/31/2005
Last Update Date	:	08/15/2018

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