Provider Demographics
NPI:1558342386
Name:WICHETA, WILLIAM EDMOND III (MD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:EDMOND
Last Name:WICHETA
Suffix:III
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:PO BOX 3027
Mailing Address - Street 2:
Mailing Address - City:WENATCHEE
Mailing Address - State:WA
Mailing Address - Zip Code:98807-3027
Mailing Address - Country:US
Mailing Address - Phone:509-662-7143
Mailing Address - Fax:509-665-4301
Practice Address - Street 1:933 RED APPLE ROAD
Practice Address - Street 2:SUITE 100
Practice Address - City:WENATCHEE
Practice Address - State:WA
Practice Address - Zip Code:98801-3370
Practice Address - Country:US
Practice Address - Phone:509-662-7143
Practice Address - Fax:509-665-4301
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00025308207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8106676Medicaid
WA8106676Medicaid