Basic Information
| Provider Information | |||||||||
| NPI: | 1487826939 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WICKSTROM | ||||||||
| FirstName: | OTTO | ||||||||
| MiddleName: | WILLIAM | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | III | ||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 583 S CLARIZZ BLVD | ||||||||
| Address2: | |||||||||
| City: | BLOOMINGTON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 474015515 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 583 S CLARIZZ BLVD | ||||||||
| Address2: | |||||||||
| City: | BLOOMINGTON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 474015515 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8123332663 | ||||||||
| FaxNumber: | 8123499206 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/25/2008 | ||||||||
| LastUpdateDate: | 04/29/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/29/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | MD61074238 | WA | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207XS0106X | MD61074238 | WA | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Hand Surgery | 174400000X | 01065381A | IN | N | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 200931500 | 05 | IN | MEDICAID |