Provider Demographics
NPI:1972544369
Name:HANSTEIN, CONRAD GEORG (MD)
Entity type:Individual
Prefix:DR
First Name:CONRAD
Middle Name:GEORG
Last Name:HANSTEIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3642 CAMINO DE LAS LOMAS
Mailing Address - Street 2:
Mailing Address - City:VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:92084-6639
Mailing Address - Country:US
Mailing Address - Phone:760-707-7286
Mailing Address - Fax:
Practice Address - Street 1:3642 CAMINO DE LAS LOMAS
Practice Address - Street 2:
Practice Address - City:VISTA
Practice Address - State:CA
Practice Address - Zip Code:92084
Practice Address - Country:US
Practice Address - Phone:760-707-7286
Practice Address - Fax:866-886-8914
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2020-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI41398-020207P00000X, 207Q00000X
CAA87958207P00000X, 207Q00000X, 207Q00000X
MN45341207P00000X, 207Q00000X
FLME 92374207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34066900Medicaid
WI34066900Medicaid
WI003200270Medicare ID - Type Unspecified