Provider Demographics
NPI:1811493737
Name:VANWICKLE, JONATHAN (MD)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:VANWICKLE
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 1:1325 E CHURCH ST STE 101
Mailing Address - Street 2:
Mailing Address - City:SANTA MARIA
Mailing Address - State:CA
Mailing Address - Zip Code:93454-5915
Mailing Address - Country:US
Mailing Address - Phone:805-925-2529
Mailing Address - Fax:805-928-4478
Practice Address - Street 1:1325 E CHURCH ST STE 101
Practice Address - Street 2:
Practice Address - City:SANTA MARIA
Practice Address - State:CA
Practice Address - Zip Code:93454-5915
Practice Address - Country:US
Practice Address - Phone:805-925-2529
Practice Address - Fax:805-928-4478
Is Sole Proprietor?:No
Enumeration Date:2018-03-30
Last Update Date:2023-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI390200000X
CAA1833342085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program