Healthcare Provider Details

I. General information

NPI: 1740228279
Provider Name (Legal Business Name): DEIRDRE A WICKHAM DO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/04/2006
Last Update Date: 01/02/2024
Certification Date: 01/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

304 1ST ST
ELK RAPIDS MI
49629-9713
US

IV. Provider business mailing address

304 1ST ST
ELK RAPIDS MI
49629-9713
US

V. Phone/Fax

Practice location:
  • Phone: 248-921-0901
  • Fax:
Mailing address:
  • Phone: 248-921-0901
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number5101010025
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: