Healthcare Provider Details

I. General information

NPI: 1043263007
Provider Name (Legal Business Name): ROCK RIVER FOOT & ANKLE CLINIC, SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/18/2006
Last Update Date: 02/26/2025
Certification Date: 02/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 OAKRIDGE CT STE A
WATERTOWN WI
53094-4150
US

IV. Provider business mailing address

PO BOX 825159
PHILADELPHIA PA
19182-5159
US

V. Phone/Fax

Practice location:
  • Phone: 920-261-9610
  • Fax: 920-261-9671
Mailing address:
  • Phone: 920-261-9610
  • Fax: 920-261-9671

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number
License Number State

VIII. Authorized Official

Name: DR. VICTOR STEPHEN SODERSTROM
Title or Position: PHYSICIAN OWNER
Credential: DPM
Phone: 920-261-9610