Provider Demographics
NPI:1518949551
Name:ENGSTROM, CONLEY WALTER (MD)
Entity Type:Individual
Prefix:
First Name:CONLEY
Middle Name:WALTER
Last Name:ENGSTROM
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 1:26908 DETROIT RD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:WESTLAKE
Mailing Address - State:OH
Mailing Address - Zip Code:44145-2398
Mailing Address - Country:US
Mailing Address - Phone:440-482-8323
Mailing Address - Fax:440-808-1606
Practice Address - Street 1:26908 DETROIT RD
Practice Address - Street 2:SUITE 103
Practice Address - City:WESTLAKE
Practice Address - State:OH
Practice Address - Zip Code:44145-2398
Practice Address - Country:US
Practice Address - Phone:440-482-8323
Practice Address - Fax:440-808-1606
Is Sole Proprietor?:No
Enumeration Date:2005-11-16
Last Update Date:2020-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH042542207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0466339Medicaid
OH0466339Medicaid
A80085Medicare UPIN