Provider Demographics
NPI:1740228279
Name:WICKHAM, DEIRDRE A (DO)
Entity Type:Individual
Prefix:DR
First Name:DEIRDRE
Middle Name:A
Last Name:WICKHAM
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:304 1ST ST
Mailing Address - Street 2:
Mailing Address - City:ELK RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49629-9713
Mailing Address - Country:US
Mailing Address - Phone:248-921-0901
Mailing Address - Fax:
Practice Address - Street 1:304 1ST ST
Practice Address - Street 2:
Practice Address - City:ELK RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49629-9713
Practice Address - Country:US
Practice Address - Phone:248-921-0901
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-04
Last Update Date:2024-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101010025207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4263995Medicaid
MI140331OtherCARE CHOICES
MIP76650OtherBLUE CROSS
MI4465272OtherAETNA
MI4357788Medicaid
MI4357788Medicaid