MEDICARE: OTTO W WICKSTROM JR. M.D. INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207X00000X	Orthopaedic Surgery Physician	01018161A	IN

General Provider Information

NPI Number	:	1447395330
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OTTO W WICKSTROM JR. M.D. INC.

Provider Business Mailing Address
First Line	:	2360 N NATIONAL RD
Second Line	:
City	:	COLUMBUS
State	:	IN
Zip	:	47201-3732
Country	:	US
Telephone Number	:	812-372-2437
Fax Number	:	812-379-2621

Provider Business Practice Location Address
First Line	:	2360 N NATIONAL RD
Second Line	:
City	:	COLUMBUS
State	:	IN
Zip	:	47201-3732
Country	:	US
Telephone Number	:	812-372-2437
Fax Number	:	812-379-2621

Authorized Official
Title or Position	:	PHYSICIAN
Name	:	DR. OTTO W WICKSTROM
Credential	:	M.D.
Telephone Number	:	812-372-2437

Provider Enumeration Date	:	02/20/2007
Last Update Date	:	08/22/2020

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