Provider Demographics
NPI:1255312161
Name:WICKLUND, MATTHEW PAUL (MD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:PAUL
Last Name:WICKLUND
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:8300 FLOYD CURL DR FL 8
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-3931
Mailing Address - Country:US
Mailing Address - Phone:210-450-9700
Mailing Address - Fax:210-450-6039
Practice Address - Street 1:8300 FLOYD CURL DR FL 8
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-3931
Practice Address - Country:US
Practice Address - Phone:210-450-9700
Practice Address - Fax:210-450-6039
Is Sole Proprietor?:No
Enumeration Date:2005-11-08
Last Update Date:2024-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.00579002084N0008X, 2084N0400X
TXU12202084N0008X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0008XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeuromuscular Medicine
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA102544971Medicaid
PA102544971Medicaid