Basic Information
| Provider Information | |||||||||
| NPI: | 1396748703 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WIEGAND | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | JOSEPH | ||||||||
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| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 549 | ||||||||
| Address2: | |||||||||
| City: | WABASH | ||||||||
| State: | IN | ||||||||
| PostalCode: | 469920549 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2605699550 | ||||||||
| FaxNumber: | 2605690760 | ||||||||
| Practice Location | |||||||||
| Address1: | 712 CAMERON WOODS DR | ||||||||
| Address2: | |||||||||
| City: | ANGOLA | ||||||||
| State: | IN | ||||||||
| PostalCode: | 46703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2606683937 | ||||||||
| FaxNumber: | 2606683794 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/31/2005 | ||||||||
| LastUpdateDate: | 08/15/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 18001620 | IN | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 000000092387 | 01 | IN | ANTHEM BCBS | OTHER | 100152890 | 05 | IN | MEDICAID |