Healthcare Provider Details

I. General information

NPI: 1669113734
Provider Name (Legal Business Name): CHANTAL BICH PHUONG WICKMAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CHANTAL BICH PHUONG PHAM MD

II. Dates (important events)

Enumeration Date: 04/05/2022
Last Update Date: 09/10/2026
Certification Date: 09/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1542 TULANE AVE # T4M2
NEW ORLEANS LA
70112-2865
US

IV. Provider business mailing address

1542 TULANE AVE # T4M2
NEW ORLEANS LA
70112-2865
US

V. Phone/Fax

Practice location:
  • Phone: 504-568-5600
  • Fax:
Mailing address:
  • Phone: 504-568-5600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number350280
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberW3632
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: