Healthcare Provider Details

I. General information

NPI: 1760415368
Provider Name (Legal Business Name): KARL OTTO WUSTRACK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/08/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1830 BLANKENSHIP RD #100
WEST LINN OR
97068-4181
US

IV. Provider business mailing address

1830 BLANKENSHIP RD #100
WEST LINN OR
97068-4181
US

V. Phone/Fax

Practice location:
  • Phone: 503-655-9727
  • Fax: 503-655-9865
Mailing address:
  • Phone: 503-655-9727
  • Fax: 503-655-9865

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberMD08363
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: