Provider Demographics
NPI:1174625610
Name:SANDSTROM, STEVEN A (MD)
Entity type:Individual
Prefix:DR
First Name:STEVEN
Middle Name:A
Last Name:SANDSTROM
Suffix:
Gender:
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:PO BOX 735044
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-5044
Mailing Address - Country:US
Mailing Address - Phone:800-326-2250
Mailing Address - Fax:
Practice Address - Street 1:210 WISCONSIN AMERICAN DR
Practice Address - Street 2:
Practice Address - City:FOND DU LAC
Practice Address - State:WI
Practice Address - Zip Code:54937-2999
Practice Address - Country:US
Practice Address - Phone:920-907-7000
Practice Address - Fax:920-907-7110
Is Sole Proprietor?:No
Enumeration Date:2006-09-04
Last Update Date:2025-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01065870A2084P0800X
WI54351-202084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100052364Medicaid
WI54351-20OtherDEPT. OF SAFETY AND PROFESSIONAL SERVICES
IN01065870AOtherINDIANA PROFESSIONAL LICENSING AGENCY