Provider Demographics
NPI:1205804614
Name:WESSELS, MICHAEL J (DPM)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:J
Last Name:WESSELS
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 E 1ST ST
Mailing Address - Street 2:STE 306
Mailing Address - City:DIXON
Mailing Address - State:IL
Mailing Address - Zip Code:61021-3166
Mailing Address - Country:US
Mailing Address - Phone:815-285-5801
Mailing Address - Fax:815-285-5699
Practice Address - Street 1:215 E 1ST ST
Practice Address - Street 2:STE 306
Practice Address - City:DIXON
Practice Address - State:IL
Practice Address - Zip Code:61021-3166
Practice Address - Country:US
Practice Address - Phone:815-285-5801
Practice Address - Fax:815-285-5699
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-10
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
T36971Medicare UPIN