Provider Demographics
NPI:1609821321
Name:LINDSTROM, JOHN RUSSELL (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:RUSSELL
Last Name:LINDSTROM
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 1:2116 CRAIG RD
Mailing Address - Street 2:
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54701-6149
Mailing Address - Country:US
Mailing Address - Phone:715-858-4650
Mailing Address - Fax:715-858-4511
Practice Address - Street 1:2116 CRAIG RD
Practice Address - Street 2:
Practice Address - City:EAU CLAIRE
Practice Address - State:WI
Practice Address - Zip Code:54701-6149
Practice Address - Country:US
Practice Address - Phone:715-858-4650
Practice Address - Fax:715-858-4511
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2011-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI22441207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
064237001OtherMEDICARE DME
WI30283000Medicaid
WI41708100OtherMEDICAID DME
WI30283000Medicaid
WI41708100OtherMEDICAID DME