Provider Demographics
NPI:1437136488
Name:WICHMAN, MARK T (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:T
Last Name:WICHMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3003 W GOOD HOPE RD
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53209-2042
Mailing Address - Country:US
Mailing Address - Phone:414-352-3100
Mailing Address - Fax:
Practice Address - Street 1:1575 N RIVERCENTER DR
Practice Address - Street 2:SUITE 160
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53212-3978
Practice Address - Country:US
Practice Address - Phone:414-274-7220
Practice Address - Fax:414-274-7227
Is Sole Proprietor?:No
Enumeration Date:2005-12-29
Last Update Date:2021-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI37933174400000X, 207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32253100Medicaid
WIP00682036OtherRR MEDICARE
WIP00682036OtherRR MEDICARE
WI32253100Medicaid
WI01994-0371Medicare PIN