Healthcare Provider Details

I. General information

NPI: 1730189820
Provider Name (Legal Business Name): NEIL WILLIAM WANGSTROM M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2005
Last Update Date: 09/16/2020
Certification Date: 09/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

304 DETROIT ST
LA PORTE IN
46350-2497
US

IV. Provider business mailing address

PO BOX 1690
LA PORTE IN
46352-1690
US

V. Phone/Fax

Practice location:
  • Phone: 219-325-3770
  • Fax: 219-325-8181
Mailing address:
  • Phone: 219-326-2312
  • Fax: 219-326-2584

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number01038858
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code207YP0228X
TaxonomyPediatric Otolaryngology Physician
License Number01038858
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code207YX0007X
TaxonomyPlastic Surgery within the Head & Neck (Otolaryngology) Physician
License Number01038858
License Number StateIN
# 4
Primary TaxonomyN
Taxonomy Code207YX0602X
TaxonomyOtolaryngic Allergy Physician
License Number01038858
License Number StateIN
# 5
Primary TaxonomyN
Taxonomy Code207YX0901X
TaxonomyOtology & Neurotology Physician
License Number01038858
License Number StateIN
# 6
Primary TaxonomyN
Taxonomy Code207YX0905X
TaxonomyOtolaryngology/Facial Plastic Surgery Physician
License Number01038858
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: