Provider Demographics
NPI:1134376486
Name:WISTROM, ELANA FRAN (DO)
Entity type:Individual
Prefix:DR
First Name:ELANA
Middle Name:FRAN
Last Name:WISTROM
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2825 PRAIRIE AVE
Mailing Address - Street 2:
Mailing Address - City:BELOIT
Mailing Address - State:WI
Mailing Address - Zip Code:53511-1844
Mailing Address - Country:US
Mailing Address - Phone:608-363-5500
Mailing Address - Fax:608-363-5539
Practice Address - Street 1:2825 PRAIRIE AVE
Practice Address - Street 2:
Practice Address - City:BELOIT
Practice Address - State:WI
Practice Address - Zip Code:53511-1844
Practice Address - Country:US
Practice Address - Phone:608-363-5500
Practice Address - Fax:608-363-5539
Is Sole Proprietor?:No
Enumeration Date:2008-08-19
Last Update Date:2013-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101017794207V00000X
WI57321-21207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1134376486Medicaid
WIWISTRELAOtherMERCYCARE INSURANCE
WI1134376486OtherBCBSWI
WI1134376486Medicaid