Basic Information
| Provider Information | |||||||||
| NPI: | 1932364627 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WEGLICKI | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | CHARLES | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | II | ||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2040 W ILES AVE STE C | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 627044183 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2177890668 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3050 MONTVALE DR STE A | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 627046924 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2177268096 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/23/2008 | ||||||||
| LastUpdateDate: | 06/29/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/29/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 2014024069 | MO | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 036135543 | IL | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 200015270 | 05 | MO | MEDICAID |