Provider Demographics
NPI:1386648731
Name:WICKUM, SUZANNE (OD)
Entity Type:Individual
Prefix:DR
First Name:SUZANNE
Middle Name:
Last Name:WICKUM
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5901 E 7TH ST
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90822-5201
Mailing Address - Country:US
Mailing Address - Phone:562-826-8000
Mailing Address - Fax:
Practice Address - Street 1:5901 E 7TH ST
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90822-5201
Practice Address - Country:US
Practice Address - Phone:562-826-8000
Practice Address - Fax:562-826-5063
Is Sole Proprietor?:No
Enumeration Date:2005-06-13
Last Update Date:2019-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10639TPA152W00000X
TX5166TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX040970801Medicaid
TX040970801Medicaid
TX82836EMedicare ID - Type Unspecified