Provider Demographics
NPI:1508866161
Name:GONSTEAD, MARY J (DC)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:J
Last Name:GONSTEAD
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:503 E CLAIREMONT AVE
Mailing Address - Street 2:
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54701-6479
Mailing Address - Country:US
Mailing Address - Phone:715-832-2223
Mailing Address - Fax:715-832-7416
Practice Address - Street 1:431 E CLAIREMONT AVE
Practice Address - Street 2:
Practice Address - City:EAU CLAIRE
Practice Address - State:WI
Practice Address - Zip Code:54701-3685
Practice Address - Country:US
Practice Address - Phone:715-832-2223
Practice Address - Fax:715-832-7416
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-26
Last Update Date:2018-10-09
Deactivation Date:2006-03-21
Deactivation Code:
Reactivation Date:2006-03-24
Provider Licenses
StateLicense IDTaxonomies
WI2063-012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI391744596019OtherBLUE CROSS
WI350010622OtherRAILROAD MEDICARE
WI350010622OtherRAILROAD MEDICARE