Healthcare Provider Details

I. General information

NPI: 1871546200
Provider Name (Legal Business Name): RONALD DOUGLAS WICHMAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/18/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 EAGLE SPRING DR SUITE A
STOCKBRIDGE GA
30281-6328
US

IV. Provider business mailing address

115 EAGLE SPRING DR SUITE A
STOCKBRIDGE GA
30281-6328
US

V. Phone/Fax

Practice location:
  • Phone: 770-474-4029
  • Fax: 770-474-2038
Mailing address:
  • Phone: 770-474-4029
  • Fax: 770-474-2038

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License Number037730
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: