=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730189820
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NEIL WILLIAM WANGSTROM M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/29/2005
-----------------------------------------------------
Last Update Date | 09/16/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 304 DETROIT ST
-----------------------------------------------------
City | LA PORTE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46350-2497
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 219-325-3770
-----------------------------------------------------
Fax | 219-325-8181
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1690
-----------------------------------------------------
City | LA PORTE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46352-1690
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 219-326-2312
-----------------------------------------------------
Fax | 219-326-2584
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Y00000X
-----------------------------------------------------
Taxonomy Name | Otolaryngology Physician
-----------------------------------------------------
License Number | 01038858
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207YP0228X
-----------------------------------------------------
Taxonomy Name | Pediatric Otolaryngology Physician
-----------------------------------------------------
License Number | 01038858
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207YX0007X
-----------------------------------------------------
Taxonomy Name | Plastic Surgery within the Head & Neck (Otolaryngology) Physician
-----------------------------------------------------
License Number | 01038858
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 207YX0602X
-----------------------------------------------------
Taxonomy Name | Otolaryngic Allergy Physician
-----------------------------------------------------
License Number | 01038858
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 207YX0901X
-----------------------------------------------------
Taxonomy Name | Otology & Neurotology Physician
-----------------------------------------------------
License Number | 01038858
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------
Taxonomy #6
-----------------------------------------------------
Taxonomy Code | 207YX0905X
-----------------------------------------------------
Taxonomy Name | Otolaryngology/Facial Plastic Surgery Physician
-----------------------------------------------------
License Number | 01038858
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------