Provider Demographics
NPI:1235634403
Name:WECKSTEIN, ETHAN (DO)
Entity Type:Individual
Prefix:
First Name:ETHAN
Middle Name:
Last Name:WECKSTEIN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:934 S GARFIELD AVE STE A
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49686-2402
Mailing Address - Country:US
Mailing Address - Phone:231-935-0355
Mailing Address - Fax:
Practice Address - Street 1:934 S GARFIELD AVE STE A
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49686-2402
Practice Address - Country:US
Practice Address - Phone:231-935-0355
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-28
Last Update Date:2022-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI51010259422084P0800X
IL036.1541552084P0800X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry