Provider Demographics
NPI:1184042855
Name:WICKENHAUSER, KEITH (MD)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:
Last Name:WICKENHAUSER
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 1:201 BJC SAINT PETERS DR STE 100
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERS
Mailing Address - State:MO
Mailing Address - Zip Code:63376-3386
Mailing Address - Country:US
Mailing Address - Phone:636-916-8200
Mailing Address - Fax:636-916-8239
Practice Address - Street 1:201 BJC SAINT PETERS DR STE 100
Practice Address - Street 2:
Practice Address - City:SAINT PETERS
Practice Address - State:MO
Practice Address - Zip Code:63376
Practice Address - Country:US
Practice Address - Phone:636-916-8200
Practice Address - Fax:636-946-5774
Is Sole Proprietor?:No
Enumeration Date:2014-03-31
Last Update Date:2019-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYR3656207R00000X
390200000X
MO2018011071207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program