Provider Demographics
NPI:1982644282
Name:WICHERT, JOHN ROBERT (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:ROBERT
Last Name:WICHERT
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 1:775 SW NINTH STREET
Mailing Address - Street 2:SUITE H
Mailing Address - City:NEWPORT
Mailing Address - State:OR
Mailing Address - Zip Code:97365-4876
Mailing Address - Country:US
Mailing Address - Phone:541-574-4767
Mailing Address - Fax:541-574-4747
Practice Address - Street 1:775 SW NINTH STREET
Practice Address - Street 2:SUITE H
Practice Address - City:NEWPORT
Practice Address - State:OR
Practice Address - Zip Code:97365-4876
Practice Address - Country:US
Practice Address - Phone:541-574-4767
Practice Address - Fax:541-574-4747
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2015-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301053932207V00000X
ORMD167094207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4679576Medicaid
OR500679017Medicaid
MI07-70022OtherPHP FAMILYCARE
OR500679017Medicaid
MI1603331183OtherBCBS/BCN
MIM21440035Medicare ID - Type UnspecifiedMEDICARE