Provider Demographics
NPI:1134120033
Name:EKSTROM, SHAWN C (MD)
Entity type:Individual
Prefix:
First Name:SHAWN
Middle Name:C
Last Name:EKSTROM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:777 ALGOMA BLVD
Mailing Address - Street 2:RADFORD HALL
Mailing Address - City:OSHKOSH
Mailing Address - State:WI
Mailing Address - Zip Code:54901-3534
Mailing Address - Country:US
Mailing Address - Phone:920-424-2424
Mailing Address - Fax:920-424-1769
Practice Address - Street 1:777 ALGOMA BLVD
Practice Address - Street 2:RADFORD HALL
Practice Address - City:OSHKOSH
Practice Address - State:WI
Practice Address - Zip Code:54901-3534
Practice Address - Country:US
Practice Address - Phone:920-424-2424
Practice Address - Fax:920-424-1769
Is Sole Proprietor?:No
Enumeration Date:2005-08-02
Last Update Date:2015-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI36923-020207Q00000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI322111700Medicaid
WI322111700Medicaid
008700416Medicare PIN