Provider Demographics
NPI:1487826939
Name:WICKSTROM, OTTO WILLIAM III (MD)
Entity Type:Individual
Prefix:DR
First Name:OTTO
Middle Name:WILLIAM
Last Name:WICKSTROM
Suffix:III
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 1:583 S CLARIZZ BLVD
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47401-5515
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:583 S CLARIZZ BLVD
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47401-5515
Practice Address - Country:US
Practice Address - Phone:812-333-2663
Practice Address - Fax:812-349-9206
Is Sole Proprietor?:No
Enumeration Date:2008-03-25
Last Update Date:2021-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD61074238207X00000X, 207XS0106X
IN01065381A174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0106XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryHand Surgery
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200931500Medicaid
IN199290JMedicare PIN
IN200931500Medicaid