Provider Demographics
NPI:1689767980
Name:HELLSTROM, WAYNE JOHN G (MD)
Entity Type:Individual
Prefix:DR
First Name:WAYNE
Middle Name:JOHN G
Last Name:HELLSTROM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:WAYNE
Other - Middle Name:G
Other - Last Name:HELLSTROM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:1430 TULANE AVE
Mailing Address - Street 2:TW22
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70112-2632
Mailing Address - Country:US
Mailing Address - Phone:504-988-2300
Mailing Address - Fax:504-988-7655
Practice Address - Street 1:1415 TULANE AVE
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70112-2600
Practice Address - Country:US
Practice Address - Phone:504-988-2300
Practice Address - Fax:504-988-7655
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2010-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA07721R208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1380814Medicaid
LA55090Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER
LA1380814Medicaid