Provider Demographics
NPI:1437179249
Name:WIKENHEISER-BROKAMP, KATHRYN (MD)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:
Last Name:WIKENHEISER-BROKAMP
Suffix:
Gender:F
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:PO BOX 636256 CENTRAL CREDENTIALING
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-6256
Mailing Address - Country:US
Mailing Address - Phone:513-585-5507
Mailing Address - Fax:513-585-5511
Practice Address - Street 1:3333 BURNET AVE # MLC1010
Practice Address - Street 2:DEPARTMENT OF PATHOLOGY AND LABORATORY MEDICINE
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45229-3026
Practice Address - Country:US
Practice Address - Phone:513-803-0239
Practice Address - Fax:513-636-3924
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2017-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-08-3105207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2424120Medicaid
OH11-01348OtherUNITED HEALTHCARE
OH7890492OtherAETNA
KY64069826Medicaid
IN200455000Medicaid
OH000000302667OtherANTHEM
OHWI4115751Medicare ID - Type Unspecified
KY64069826Medicaid