Provider Demographics
NPI:1225039365
Name:NORDSTROM, DONALD GENE (MD)
Entity Type:Individual
Prefix:DR
First Name:DONALD
Middle Name:GENE
Last Name:NORDSTROM
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 1:420 E DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:FOND DU LAC
Mailing Address - State:WI
Mailing Address - Zip Code:54935-4560
Mailing Address - Country:US
Mailing Address - Phone:920-926-4100
Mailing Address - Fax:712-264-6553
Practice Address - Street 1:480 E DIVISION ST
Practice Address - Street 2:
Practice Address - City:FOND DU LAC
Practice Address - State:WI
Practice Address - Zip Code:54935-3734
Practice Address - Country:US
Practice Address - Phone:920-926-4100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-10
Last Update Date:2021-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI709132085R0001X
IA320282085R0001X
MN227422085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA920005055OtherRR MEDICARE
IA1990903Medicaid
IA49561OtherIA BLUESHIELD
IAI20290Medicare PIN
IA1990903Medicaid