Provider Demographics
NPI:1285692525
Name:WIEGANDT, AMY GLEASON (MD)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:GLEASON
Last Name:WIEGANDT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:LOUISE
Other - Last Name:GLEASON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:2621 CRANBERRY HIGHWAY
Mailing Address - Street 2:
Mailing Address - City:WAREHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02571
Mailing Address - Country:US
Mailing Address - Phone:508-295-4902
Mailing Address - Fax:508-295-2455
Practice Address - Street 1:2621 CRANBERRY HIGHWAY
Practice Address - Street 2:
Practice Address - City:WAREHAM
Practice Address - State:MA
Practice Address - Zip Code:02571
Practice Address - Country:US
Practice Address - Phone:508-295-4902
Practice Address - Fax:508-295-2455
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-03
Last Update Date:2008-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA57120207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA754275OtherTUFTS HLTH PLAN
MA61516OtherHARVARD PILGRAM
MA110206873OtherMEDICARE RAILROAD
MA3032736Medicaid
MA3032736Medicaid
B74910Medicare UPIN