Provider Demographics
NPI:1669483897
Name:WOLLHEIM, DONALD ALAN (MD WCC)
Entity type:Individual
Prefix:DR
First Name:DONALD
Middle Name:ALAN
Last Name:WOLLHEIM
Suffix:
Gender:M
Credentials:MD WCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N8748 HUSTISFORD RD
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:WI
Mailing Address - Zip Code:53094-9554
Mailing Address - Country:US
Mailing Address - Phone:920-261-4069
Mailing Address - Fax:
Practice Address - Street 1:N8748 HUSTISFORD RD
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:WI
Practice Address - Zip Code:53094-9554
Practice Address - Country:US
Practice Address - Phone:920-261-4069
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2022-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI20951020208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30384200Medicaid
WI30384200Medicaid