Basic Information
Provider Information | |||||||||
NPI: | 1447228325 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WICKMAN | ||||||||
FirstName: | DOUGLAS | ||||||||
MiddleName: | W | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 2000 | ||||||||
Address2: |   | ||||||||
City: | HUDSON | ||||||||
State: | NY | ||||||||
PostalCode: | 125342000 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5188288363 | ||||||||
FaxNumber: | 5186973388 | ||||||||
Practice Location | |||||||||
Address1: | 71 PROSPECT AVE | ||||||||
Address2: |   | ||||||||
City: | HUDSON | ||||||||
State: | NY | ||||||||
PostalCode: | 125342907 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5186973208 | ||||||||
FaxNumber: | 5186973207 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/08/2006 | ||||||||
LastUpdateDate: | 05/20/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | MD23937 | OR | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 207R00000X | 248055 | NY | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 286348 | 05 | OR |   | MEDICAID |