Provider Demographics
NPI:1104864941
Name:WICKHAM, JAMES (MD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:
Last Name:WICKHAM
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 1:27401 LOS ALTOS
Mailing Address - Street 2:SUITE 180
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92691-6316
Mailing Address - Country:US
Mailing Address - Phone:949-582-9624
Mailing Address - Fax:949-582-9626
Practice Address - Street 1:27401 LOS ALTOS
Practice Address - Street 2:SUITE 180
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92691-6316
Practice Address - Country:US
Practice Address - Phone:949-582-9624
Practice Address - Fax:949-582-9626
Is Sole Proprietor?:No
Enumeration Date:2006-06-03
Last Update Date:2008-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG69601207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G696010Medicaid
CA00G696010Medicaid
WG69601BMedicare PIN