Provider Demographics
NPI:1508810110
Name:SODERSTROM, VICTOR STEPHEN (DPM)
Entity Type:Individual
Prefix:DR
First Name:VICTOR
Middle Name:STEPHEN
Last Name:SODERSTROM
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:101 OAKRIDGE CT
Mailing Address - Street 2:STE A
Mailing Address - City:WATERTOWN
Mailing Address - State:WI
Mailing Address - Zip Code:53094-4150
Mailing Address - Country:US
Mailing Address - Phone:920-261-9610
Mailing Address - Fax:920-261-9671
Practice Address - Street 1:101 OAKRIDGE CT
Practice Address - Street 2:STE A
Practice Address - City:WATERTOWN
Practice Address - State:WI
Practice Address - Zip Code:53094-4150
Practice Address - Country:US
Practice Address - Phone:920-261-9610
Practice Address - Fax:920-261-9671
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2009-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI444025213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43200300Medicaid
WI43200300Medicaid
WI864350002Medicare ID - Type Unspecified