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:
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Health care specialties

SpecialtyCodeLicense #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.

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Identifiers

StateTypeNumberIssuer
All States NPI 1669476123 NPPES
Arizona MEDICAID 446866

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