MEDICARE: DR. THOMAS JOSEPH WEGMAN PH.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	103G00000X	Clinical Neuropsychologist	PSY4228	CA
2	103TC0700X	Clinical Psychologist	PSY4228	CA

General Provider Information

NPI Number	:	1568512143
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. THOMAS JOSEPH WEGMAN PH.D.

Provider Business Mailing Address
First Line	:	5190 GOVERNOR DR STE 104
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92122-2848
Country	:	US
Telephone Number	:	858-455-5252
Fax Number	:	858-455-5556

Provider Business Practice Location Address
First Line	:	5190 GOVERNOR DR STE 104
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92122-2848
Country	:	US
Telephone Number	:	858-455-5252
Fax Number	:	858-455-5556

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

Provider Enumeration Date	:	01/12/2007
Last Update Date	:	07/15/2013

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