Provider Demographics
NPI:1093991788
Name:WIJKSTROM, MARTIN NICOLAS (MD)
Entity Type:Individual
Prefix:DR
First Name:MARTIN
Middle Name:NICOLAS
Last Name:WIJKSTROM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2359 RAILROAD ST
Mailing Address - Street 2:APT 2502
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15222-5601
Mailing Address - Country:US
Mailing Address - Phone:612-578-4700
Mailing Address - Fax:
Practice Address - Street 1:3459 5TH AVE
Practice Address - Street 2:UPMC MONTEFIORE, 7 SOUTH
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15213-3236
Practice Address - Country:US
Practice Address - Phone:412-647-5738
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-13
Last Update Date:2010-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA000316208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery