Provider Demographics
NPI:1679564975
Name:WALSTRUM, JOHN (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:WALSTRUM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:551 LINN ST
Mailing Address - Street 2:
Mailing Address - City:ALLEGAN
Mailing Address - State:MI
Mailing Address - Zip Code:49010-1595
Mailing Address - Country:US
Mailing Address - Phone:269-686-5800
Mailing Address - Fax:269-686-5899
Practice Address - Street 1:551 LINN ST
Practice Address - Street 2:
Practice Address - City:ALLEGAN
Practice Address - State:MI
Practice Address - Zip Code:49010-1595
Practice Address - Country:US
Practice Address - Phone:269-686-5800
Practice Address - Fax:269-686-5899
Is Sole Proprietor?:No
Enumeration Date:2005-11-04
Last Update Date:2015-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIJW042924207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI25685OtherCOMMUNITY CHOICE OF MI
080067212OtherRAILROAD MEDICARE
1837425OtherUNITED HEALTHCARE
MI0800300041OtherBCBS MI PROV #
MI20476OtherHEALTH PLAN OF MI
MIP53510OtherBLUE CARE NETWORK
01-30460OtherPHP PROV #
MIJW042924OtherSTATE LINCENSE #
MIP00361391OtherRAILROAD MEDICARE
MI1353542Medicaid
MI20476OtherHEALTH PLAN OF MI
MIP53510OtherBLUE CARE NETWORK
MI25685OtherCOMMUNITY CHOICE OF MI