Individual
DR. OTTO WILLIAM WICKSTROM III
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
583 S CLARIZZ BLVD, BLOOMINGTON, IN 47401-5515
(812) 333-2663
(812) 349-9206
Mailing address
583 S CLARIZZ BLVD, BLOOMINGTON, IN 47401-5515
Taxonomy
Speciality
Code
Description
License number
State
174400000X
Specialist
01065381A
IN
207X00000X
Orthopaedic Surgery Physician
MD61074238
WA
207XS0106X
Orthopaedic Hand Surgery Physician
Primary
MD61074238
WA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
200931500
—
IN
Enumeration date
03/25/2008
Last updated
04/29/2021
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