Provider Demographics
NPI:1952346553
Name:WIKSTROM, THOMAS ROBERT (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:ROBERT
Last Name:WIKSTROM
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 1:6817 SOUTHPOINT PKWY
Mailing Address - Street 2:SUITE 2503
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-6282
Mailing Address - Country:US
Mailing Address - Phone:904-396-0425
Mailing Address - Fax:904-396-0448
Practice Address - Street 1:6817 SOUTHPOINT PKWY
Practice Address - Street 2:SUITE 2503
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-6282
Practice Address - Country:US
Practice Address - Phone:904-396-0425
Practice Address - Fax:904-396-0448
Is Sole Proprietor?:No
Enumeration Date:2006-06-18
Last Update Date:2016-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME00521612084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1952346553OtherNPI
FL1952346553OtherNPI
FLE22425Medicare UPIN