Provider Demographics
NPI:1154901528
Name:WEGLARZ, TIERRA LEE (DO)
Entity type:Individual
Prefix:
First Name:TIERRA
Middle Name:LEE
Last Name:WEGLARZ
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:TIERRA
Other - Middle Name:LEE
Other - Last Name:FOLSOM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:5111 N GLEN PARK PLACE RD
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-4675
Mailing Address - Country:US
Mailing Address - Phone:309-683-5700
Mailing Address - Fax:
Practice Address - Street 1:5111 N GLEN PARK PLACE RD
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-4675
Practice Address - Country:US
Practice Address - Phone:309-683-5700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-10
Last Update Date:2024-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
90200000X390200000X
IL036170921207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program