Individual
KARL THEODORE WICKSTROM
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
790 GAIL GARDNER WAY, PRESCOTT, AZ 86305-2337
(928) 776-9900
(928) 776-1444
Mailing address
790 GAIL GARDNER WAY, PRESCOTT, AZ 86305-2337
(928) 776-9900
(928) 776-1444
Taxonomy
Speciality
Code
Description
License number
State
2085R0202X
Diagnostic Radiology Physician
Primary
21726
AZ
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
446866
—
AZ
Enumeration date
06/10/2005
Last updated
02/28/2013
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