Provider Demographics
NPI:1104189166
Name:WETSTEIN, PAUL (MD)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:
Last Name:WETSTEIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3105 FIELDS SOUTH DR
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61822-3743
Mailing Address - Country:US
Mailing Address - Phone:217-383-3240
Mailing Address - Fax:
Practice Address - Street 1:3105 FIELDS SOUTH DR
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61822-3743
Practice Address - Country:US
Practice Address - Phone:217-383-3240
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-24
Last Update Date:2024-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME1356432086S0102X
390200000X
IL036166628208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
HIVAD000Medicare UPIN