Provider Demographics
NPI:1417947540
Name:WIERSMA, RUSTAN J (MD)
Entity Type:Individual
Prefix:
First Name:RUSTAN
Middle Name:J
Last Name:WIERSMA
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 1:191 THEATRE RD
Mailing Address - Street 2:
Mailing Address - City:ONALASKA
Mailing Address - State:WI
Mailing Address - Zip Code:54650-8679
Mailing Address - Country:US
Mailing Address - Phone:608-392-5000
Mailing Address - Fax:
Practice Address - Street 1:191 THEATRE RD
Practice Address - Street 2:
Practice Address - City:ONALASKA
Practice Address - State:WI
Practice Address - Zip Code:54650-8679
Practice Address - Country:US
Practice Address - Phone:608-392-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-28
Last Update Date:2012-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI23302207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
B57611Medicare UPIN