Provider Demographics
NPI:1831198647
Name:WIKHOLM, RICHARD P (MD)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:P
Last Name:WIKHOLM
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:PO BOX 5427
Mailing Address - Street 2:
Mailing Address - City:SANTA MARIA
Mailing Address - State:CA
Mailing Address - Zip Code:93456-5427
Mailing Address - Country:US
Mailing Address - Phone:805-614-6250
Mailing Address - Fax:805-614-9260
Practice Address - Street 1:116 S PALISADE DR
Practice Address - Street 2:STE 206
Practice Address - City:SANTA MARIA
Practice Address - State:CA
Practice Address - Zip Code:93454-8904
Practice Address - Country:US
Practice Address - Phone:805-614-9250
Practice Address - Fax:805-614-9260
Is Sole Proprietor?:No
Enumeration Date:2005-07-14
Last Update Date:2009-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG55811207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G558110Medicaid
G55811Medicare ID - Type Unspecified
040014761Medicare ID - Type UnspecifiedRAILROAD
CA00G558110Medicaid