Provider Demographics
NPI:1417065848
Name:WICKLUND, ROGER A (MD)
Entity Type:Individual
Prefix:DR
First Name:ROGER
Middle Name:A
Last Name:WICKLUND
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:9135 SW BARNES RD
Mailing Address - Street 2:STE. 663
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97225-6646
Mailing Address - Country:US
Mailing Address - Phone:503-297-1078
Mailing Address - Fax:503-292-2176
Practice Address - Street 1:9135 SW BARNES RD
Practice Address - Street 2:STE. 663
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-6646
Practice Address - Country:US
Practice Address - Phone:503-297-1078
Practice Address - Fax:503-292-2176
Is Sole Proprietor?:No
Enumeration Date:2006-08-27
Last Update Date:2012-10-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
ORMD09630208800000X
WAMD00034648208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology