Provider Demographics
NPI:1356333736
Name:WICHMANN-WALCZAK, JOHN STANLEY (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:STANLEY
Last Name:WICHMANN-WALCZAK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:JOHN
Other - Middle Name:STANLEY
Other - Last Name:WALCZAK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:94-837 WAIPAHU ST
Mailing Address - Street 2:
Mailing Address - City:WAIPAHU
Mailing Address - State:HI
Mailing Address - Zip Code:96797-3320
Mailing Address - Country:US
Mailing Address - Phone:808-671-3911
Mailing Address - Fax:808-677-2720
Practice Address - Street 1:94-837 WAIPAHU ST
Practice Address - Street 2:
Practice Address - City:WAIPAHU
Practice Address - State:HI
Practice Address - Zip Code:96797-3320
Practice Address - Country:US
Practice Address - Phone:808-671-3911
Practice Address - Fax:808-677-2720
Is Sole Proprietor?:No
Enumeration Date:2005-08-22
Last Update Date:2018-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMD2647208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI013771-03Medicaid
HI00E001467-9OtherHMSA PROVIDER NUMBER
151218OtherMEDICARE PIN NUMBER