Basic Information
Provider Information | |||||||||
NPI: | 1801188792 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WIEGEL | ||||||||
FirstName: | MICAH | ||||||||
MiddleName: | DAVID | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 724 N SPRING ST STE A | ||||||||
Address2: |   | ||||||||
City: | HARRISON | ||||||||
State: | AR | ||||||||
PostalCode: | 726012913 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8703650850 | ||||||||
FaxNumber: | 8703650862 | ||||||||
Practice Location | |||||||||
Address1: | 724 N SPRING ST | ||||||||
Address2: |   | ||||||||
City: | HARRISON | ||||||||
State: | AR | ||||||||
PostalCode: | 726012913 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8703650850 | ||||||||
FaxNumber: | 8703650862 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/10/2011 | ||||||||
LastUpdateDate: | 09/19/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 09/19/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X |   |   | N |   | Student, Health Care | Student in an Organized Health Care Education/Training Program |   | 207V00000X | E-9098 | AR | Y |   | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |   |
No ID Information.