Provider Demographics
NPI:1356332498
Name:WOLLSTADT, LOYD J (MD)
Entity type:Individual
Prefix:DR
First Name:LOYD
Middle Name:J
Last Name:WOLLSTADT
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Gender:M
Credentials:MD
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Mailing Address - Street 1:1601 PARKVIEW AVE
Mailing Address - Street 2:CREDENTIALING S200
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107-1822
Mailing Address - Country:US
Mailing Address - Phone:815-395-5861
Mailing Address - Fax:815-395-5575
Practice Address - Street 1:405 CHARLES ST
Practice Address - Street 2:UNIVERSITY PRIMARY CARE CLINIC MT MORRIS
Practice Address - City:MOUNT MORRIS
Practice Address - State:IL
Practice Address - Zip Code:61054-1646
Practice Address - Country:US
Practice Address - Phone:815-734-6061
Practice Address - Fax:815-734-9021
Is Sole Proprietor?:No
Enumeration Date:2005-10-28
Last Update Date:2010-09-03
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Provider Licenses
StateLicense IDTaxonomies
IL036050197207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036050197Medicaid
IL036050197OtherIL STATE LICENSE
IL250470Medicare PIN
ILC38343Medicare UPIN