Provider Demographics
NPI:1588810808
Name:WICKBOLDT, LLOYD GEORGE (MD)
Entity Type:Individual
Prefix:DR
First Name:LLOYD
Middle Name:GEORGE
Last Name:WICKBOLDT
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 1:6630 PATIO LN
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33433-6631
Mailing Address - Country:US
Mailing Address - Phone:561-369-7153
Mailing Address - Fax:561-369-7153
Practice Address - Street 1:6630 PATIO LN
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33433-6631
Practice Address - Country:US
Practice Address - Phone:561-369-7153
Practice Address - Fax:561-369-7153
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-18
Last Update Date:2008-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 35683207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology