Wickstrom, Karl Theodore
Wickstrom, Karl Theodore is an individual health care provider with primary practice located at 790 Gail Gardner Way , Prescott AZ 86305-2337. He recently has only one registered license in Allopathic & Osteopathic Physicians / Diagnostic Radiology, which is considered as his primary health care specialty. Wickstrom, Karl Theodore can be contacted via phone (928) 776-9900.Contact Information
Primary practice address
790 Gail Gardner Way
Prescott AZ 86305-2337
Phone: (928) 776-9900
Fax: (928) 776-1444
Website:
Health care specialties
| Specialty | Code | License # | State |
|---|---|---|---|
| Allopathic & Osteopathic Physicians / Diagnostic Radiology | 2085R0202X | 21726 | Arizona |
Profile Details
| NPI number | 1669476123 |
|---|---|
| LBN Legal business name | Wickstrom, Karl Theodore |
| Credentials | Doctor of Medicine (MD) |
| Entity | Individual |
| Sole proprietor 1 | No |
| Enumeration date | Jun 10th, 2005 |
| Last updated | Feb 28th, 2013 - about 12 years ago |
1 A sole proprietor/sole proprietorship is an individual, and in that capacity, is qualified for a solitary NPI number. The sole proprietor have to apply for the NPI number using his or her own particular Social Security Number (SSN), instead of Employer Identification Number (EIN) regardless of whether he/she has an EIN.
Identifiers
| State | Type | Number | Issuer |
|---|---|---|---|
| All States | NPI | 1669476123 | NPPES |
| Arizona | MEDICAID | 446866 |
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