Healthcare Provider Details

I. General information

NPI: 1104838309
Provider Name (Legal Business Name): CHRISTOPHER M WIRSING D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/13/2006
Last Update Date: 03/01/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

880 EASTPORT CENTRE DR SUITE 200
VALPARAISO IN
46383-2909
US

IV. Provider business mailing address

880 EASTPORT CENTRE DR SUITE 200
VALPARAISO IN
46383-2909
US

V. Phone/Fax

Practice location:
  • Phone: 219-464-0409
  • Fax: 219-464-2376
Mailing address:
  • Phone: 219-464-0409
  • Fax: 219-464-2376

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number02000885A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: