Provider Demographics
NPI:1003814336
Name:WIESZTORT, WALTER RUDOLPH (DC)
Entity Type:Individual
Prefix:DR
First Name:WALTER
Middle Name:RUDOLPH
Last Name:WIESZTORT
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4014 77TH ST
Mailing Address - Street 2:STE. 2
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53142-4314
Mailing Address - Country:US
Mailing Address - Phone:262-694-3530
Mailing Address - Fax:262-925-8810
Practice Address - Street 1:4014 77TH ST
Practice Address - Street 2:STE. 2
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53142-4314
Practice Address - Country:US
Practice Address - Phone:262-694-3530
Practice Address - Fax:262-925-8810
Is Sole Proprietor?:No
Enumeration Date:2005-07-11
Last Update Date:2008-04-22
Deactivation Date:2006-03-16
Deactivation Code:
Reactivation Date:2006-03-24
Provider Licenses
StateLicense IDTaxonomies
WI3514-012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38911900Medicaid
521540114OtherMACS
4400259OtherUHC
0005896742OtherAETNA
0191565OtherCIGNA
WI721524922010OtherBLUE CROSS BLUE SHIELD
521540114OtherMACS
WI38911900Medicaid