Provider Demographics
NPI:1447395330
Name:OTTO W WICKSTROM JR. M.D. INC.
Entity Type:Organization
Organization Name:OTTO W WICKSTROM JR. M.D. INC.
Other - Org Name:OTTO W WICKSTROM JR. M.D. INC.
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:OTTO
Authorized Official - Middle Name:W
Authorized Official - Last Name:WICKSTROM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:812-372-2437
Mailing Address - Street 1:2360 N NATIONAL RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:IN
Mailing Address - Zip Code:47201-3732
Mailing Address - Country:US
Mailing Address - Phone:812-372-2437
Mailing Address - Fax:812-379-2621
Practice Address - Street 1:2360 N NATIONAL RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:IN
Practice Address - Zip Code:47201-3732
Practice Address - Country:US
Practice Address - Phone:812-372-2437
Practice Address - Fax:812-379-2621
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01018161A207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN050780Medicare ID - Type Unspecified
INC24174Medicare UPIN