Provider Demographics
NPI:1013070200
Name:WEGENER, MARK EUGENE (DPT)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:EUGENE
Last Name:WEGENER
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23832 ROCKFIELD BLVD STE 160
Mailing Address - Street 2:
Mailing Address - City:LAKE FOREST
Mailing Address - State:CA
Mailing Address - Zip Code:92630-2820
Mailing Address - Country:US
Mailing Address - Phone:949-465-9500
Mailing Address - Fax:949-465-9506
Practice Address - Street 1:23832 ROCKFIELD BLVD STE 160
Practice Address - Street 2:
Practice Address - City:LAKE FOREST
Practice Address - State:CA
Practice Address - Zip Code:92630-2820
Practice Address - Country:US
Practice Address - Phone:949-465-9500
Practice Address - Fax:949-465-9506
Is Sole Proprietor?:No
Enumeration Date:2006-12-18
Last Update Date:2018-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT24624225100000X, 2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWPT24624BMedicare ID - Type UnspecifiedPPIN