Healthcare Provider Details

I. General information

NPI: 1235634403
Provider Name (Legal Business Name): ETHAN WECKSTEIN D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/28/2018
Last Update Date: 07/28/2022
Certification Date: 07/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

934 S GARFIELD AVE STE A
TRAVERSE CITY MI
49686-2402
US

IV. Provider business mailing address

934 S GARFIELD AVE STE A
TRAVERSE CITY MI
49686-2402
US

V. Phone/Fax

Practice location:
  • Phone: 231-935-0355
  • Fax:
Mailing address:
  • Phone: 231-935-0355
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number5101025942
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number036.154155
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: