Provider Demographics
NPI:1417170846
Name:ENGSTROM, DAVID WAYNE (DC)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:WAYNE
Last Name:ENGSTROM
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1240 13TH AVENUE
Mailing Address - Street 2:
Mailing Address - City:GRAFTON
Mailing Address - State:WI
Mailing Address - Zip Code:53024
Mailing Address - Country:US
Mailing Address - Phone:262-375-1470
Mailing Address - Fax:262-375-3580
Practice Address - Street 1:1240 13TH AVENUE
Practice Address - Street 2:
Practice Address - City:GRAFTON
Practice Address - State:WI
Practice Address - Zip Code:53024
Practice Address - Country:US
Practice Address - Phone:262-375-1470
Practice Address - Fax:262-375-3580
Is Sole Proprietor?:No
Enumeration Date:2007-04-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1485111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38762500Medicaid
T61863Medicare UPIN
WI75238Medicare ID - Type Unspecified