Provider Demographics
NPI:1447450143
Name:WEICKERT, THELSA THOMAS (MD)
Entity type:Individual
Prefix:
First Name:THELSA
Middle Name:THOMAS
Last Name:WEICKERT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:THELSA
Other - Middle Name:THOMAS
Other - Last Name:PULIKKOTIL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:160 DENTAL CIRCLE
Mailing Address - Street 2:CAMPUS BOX 7075
Mailing Address - City:CHAPEL HILL
Mailing Address - State:NC
Mailing Address - Zip Code:27599
Mailing Address - Country:US
Mailing Address - Phone:919-966-5201
Mailing Address - Fax:919-966-1743
Practice Address - Street 1:160 DENTAL CIRCLE
Practice Address - Street 2:CAMPUS BOX 7075
Practice Address - City:CHAPEL HILL
Practice Address - State:NC
Practice Address - Zip Code:27599
Practice Address - Country:US
Practice Address - Phone:919-966-5201
Practice Address - Fax:919-966-1743
Is Sole Proprietor?:No
Enumeration Date:2007-07-20
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO45875207R00000X
GA068543207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO55186017Medicaid
CO55186017Medicaid