Provider Demographics
NPI:1730189820
Name:WANGSTROM, NEIL WILLIAM (MD)
Entity type:Individual
Prefix:DR
First Name:NEIL
Middle Name:WILLIAM
Last Name:WANGSTROM
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:PO BOX 1690
Mailing Address - Street 2:
Mailing Address - City:LA PORTE
Mailing Address - State:IN
Mailing Address - Zip Code:46352-1690
Mailing Address - Country:US
Mailing Address - Phone:219-326-2312
Mailing Address - Fax:219-326-2584
Practice Address - Street 1:304 DETROIT ST
Practice Address - Street 2:
Practice Address - City:LA PORTE
Practice Address - State:IN
Practice Address - Zip Code:46350-2497
Practice Address - Country:US
Practice Address - Phone:219-325-3770
Practice Address - Fax:219-325-8181
Is Sole Proprietor?:No
Enumeration Date:2005-07-29
Last Update Date:2020-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01038858207Y00000X, 207YP0228X, 207YX0007X, 207YX0602X, 207YX0901X, 207YX0905X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
No207YP0228XAllopathic & Osteopathic PhysiciansOtolaryngologyPediatric Otolaryngology
No207YX0007XAllopathic & Osteopathic PhysiciansOtolaryngologyPlastic Surgery within the Head & Neck
No207YX0602XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngic Allergy
No207YX0901XAllopathic & Osteopathic PhysiciansOtolaryngologyOtology & Neurotology
No207YX0905XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngology/Facial Plastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
INM400041676OtherMEDICARE PTAN
IN000000697664OtherANTHEM
IN100165330Medicaid
IN100165330Medicaid