Individual
DR. NEIL WILLIAM WANGSTROM
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
304 DETROIT ST, LA PORTE, IN 46350-2497
(219) 325-3770
(219) 325-8181
Mailing address
PO BOX 1690, LA PORTE, IN 46352-1690
(219) 326-2312
(219) 326-2584
Taxonomy
Speciality
Code
Description
License number
State
207Y00000X
Otolaryngology Physician
Primary
01038858
IN
207YP0228X
Pediatric Otolaryngology Physician
01038858
IN
207YX0007X
Plastic Surgery within the Head & Neck (Otolaryngology) Physician
01038858
IN
207YX0602X
Otolaryngic Allergy Physician
01038858
IN
207YX0901X
Otology & Neurotology Physician
01038858
IN
207YX0905X
Otolaryngology/Facial Plastic Surgery Physician
01038858
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000000697664
ANTHEM
IN
05
—
100165330
—
IN
01
—
M400041676
MEDICARE PTAN
IN
Enumeration date
07/29/2005
Last updated
09/16/2020
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