Basic Information
| Provider Information | |||||||||
| NPI: | 1447450143 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WEICKERT | ||||||||
| FirstName: | THELSA | ||||||||
| MiddleName: | THOMAS | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | PULIKKOTIL | ||||||||
| OtherFirstName: | THELSA | ||||||||
| OtherMiddleName: | THOMAS | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 160 DENTAL CIRCLE | ||||||||
| Address2: | CAMPUS BOX 7075 | ||||||||
| City: | CHAPEL HILL | ||||||||
| State: | NC | ||||||||
| PostalCode: | 27599 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9199665201 | ||||||||
| FaxNumber: | 9199661743 | ||||||||
| Practice Location | |||||||||
| Address1: | 160 DENTAL CIRCLE | ||||||||
| Address2: | CAMPUS BOX 7075 | ||||||||
| City: | CHAPEL HILL | ||||||||
| State: | NC | ||||||||
| PostalCode: | 27599 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9199665201 | ||||||||
| FaxNumber: | 9199661743 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/20/2007 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 45875 | CO | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RC0000X | 068543 | GA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 55186017 | 05 | CO | MEDICAID |