Provider Demographics
NPI:1447228325
Name:WICKMAN, DOUGLAS W (MD)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:W
Last Name:WICKMAN
Suffix:
Gender:M
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 2000
Mailing Address - Street 2:
Mailing Address - City:HUDSON
Mailing Address - State:NY
Mailing Address - Zip Code:12534-2000
Mailing Address - Country:US
Mailing Address - Phone:518-828-8363
Mailing Address - Fax:518-697-3388
Practice Address - Street 1:71 PROSPECT AVE
Practice Address - Street 2:
Practice Address - City:HUDSON
Practice Address - State:NY
Practice Address - Zip Code:12534-2907
Practice Address - Country:US
Practice Address - Phone:518-697-3208
Practice Address - Fax:518-697-3207
Is Sole Proprietor?:No
Enumeration Date:2006-03-08
Last Update Date:2008-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD23937207R00000X
NY248055207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR286348Medicaid
ORRR PTAN P00263710Medicare PIN
ORR131387Medicare PIN
G68551Medicare UPIN