Provider Demographics
NPI:1932312022
Name:BICKELL, KIMBERLY WYCOFF (MD)
Entity Type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:WYCOFF
Last Name:BICKELL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:KIMBERLY
Other - Middle Name:SUZANNE
Other - Last Name:WYCOFF
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1021 5TH STREET #104
Mailing Address - Street 2:GNH #3550
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90403
Mailing Address - Country:US
Mailing Address - Phone:310-804-6525
Mailing Address - Fax:
Practice Address - Street 1:1200 N. STATE STREET
Practice Address - Street 2:GNH #3550
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90033
Practice Address - Country:US
Practice Address - Phone:323-226-7257
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA942252085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology