Provider Demographics
NPI:1326000803
Name:WICHMANN, PHILIP F (MD)
Entity Type:Individual
Prefix:
First Name:PHILIP
Middle Name:F
Last Name:WICHMANN
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 1:2050 S BLOSSER RD
Mailing Address - Street 2:
Mailing Address - City:SANTA MARIA
Mailing Address - State:CA
Mailing Address - Zip Code:93458-7310
Mailing Address - Country:US
Mailing Address - Phone:805-361-8028
Mailing Address - Fax:805-361-8097
Practice Address - Street 1:7512 MORRO RD
Practice Address - Street 2:
Practice Address - City:ATASCADERO
Practice Address - State:CA
Practice Address - Zip Code:93422-4404
Practice Address - Country:US
Practice Address - Phone:805-792-1400
Practice Address - Fax:805-792-1485
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-03
Last Update Date:2015-06-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN23016207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN701088500Medicaid
110004099Medicare ID - Type Unspecified
MN701088500Medicaid