Provider Demographics
NPI:1174756316
Name:WETTSTEIN, DANIEL MATTHEW (DPM)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:MATTHEW
Last Name:WETTSTEIN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60285 RIDGELINE DR.
Mailing Address - Street 2:SUITE 101
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84405
Mailing Address - Country:US
Mailing Address - Phone:801-475-5239
Mailing Address - Fax:801-475-5286
Practice Address - Street 1:476 CHENEY DRIVE WEST
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301
Practice Address - Country:US
Practice Address - Phone:208-731-6321
Practice Address - Fax:801-475-5286
Is Sole Proprietor?:No
Enumeration Date:2009-09-03
Last Update Date:2012-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT0000001213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery