Basic Information
| Provider Information | |||||||||
| NPI: | 1356332498 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WOLLSTADT | ||||||||
| FirstName: | LOYD | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1601 PARKVIEW AVE | ||||||||
| Address2: | CREDENTIALING S200 | ||||||||
| City: | ROCKFORD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 611071822 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8153955861 | ||||||||
| FaxNumber: | 8153955575 | ||||||||
| Practice Location | |||||||||
| Address1: | 405 CHARLES ST | ||||||||
| Address2: | UNIVERSITY PRIMARY CARE CLINIC MT MORRIS | ||||||||
| City: | MOUNT MORRIS | ||||||||
| State: | IL | ||||||||
| PostalCode: | 610541646 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8157346061 | ||||||||
| FaxNumber: | 8157349021 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/28/2005 | ||||||||
| LastUpdateDate: | 09/03/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 036050197 | IL | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 036050197 | 05 | IL | MEDICAID | 036050197 | 01 | IL | IL STATE LICENSE | OTHER |