Provider Demographics
NPI:1760534879
Name:WICHMAN, PAUL H (MD)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:H
Last Name:WICHMAN
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 1:39 MAPLE AVENUE
Mailing Address - Street 2:
Mailing Address - City:NETCONG
Mailing Address - State:NJ
Mailing Address - Zip Code:07857
Mailing Address - Country:US
Mailing Address - Phone:973-347-4121
Mailing Address - Fax:973-347-1545
Practice Address - Street 1:39 MAPLE AVENUE
Practice Address - Street 2:
Practice Address - City:NETCONG
Practice Address - State:NJ
Practice Address - Zip Code:07857
Practice Address - Country:US
Practice Address - Phone:973-347-4121
Practice Address - Fax:973-347-1545
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-17
Last Update Date:2010-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA039719207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1917102Medicaid
186273Medicare PIN
C53967Medicare UPIN