Provider Demographics
NPI:1811974934
Name:WICKHAM, NEIL E (MD)
Entity type:Individual
Prefix:
First Name:NEIL
Middle Name:E
Last Name:WICKHAM
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 1:2055 KIMBALL AVE STE 400
Mailing Address - Street 2:
Mailing Address - City:WATERLOO
Mailing Address - State:IA
Mailing Address - Zip Code:50702-5047
Mailing Address - Country:US
Mailing Address - Phone:319-272-0000
Mailing Address - Fax:319-272-1329
Practice Address - Street 1:2055 KIMBALL AVE STE 400
Practice Address - Street 2:
Practice Address - City:WATERLOO
Practice Address - State:IA
Practice Address - Zip Code:50702-5047
Practice Address - Country:US
Practice Address - Phone:319-272-0000
Practice Address - Fax:319-272-1329
Is Sole Proprietor?:No
Enumeration Date:2005-12-29
Last Update Date:2023-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA31935207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1811974934Medicaid
IA2140343Medicaid
IAP00287732OtherRR MEDICARE
IA3140343Medicaid
IA2140343Medicaid
IA1811974934Medicaid