Healthcare Provider Details

I. General information

NPI: 1487624953
Provider Name (Legal Business Name): SUSAN M WICKLUND M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/25/2006
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

207 S MAIN ST
LIVINGSTON MT
59047-3016
US

IV. Provider business mailing address

207 S MAIN ST
LIVINGSTON MT
59047-3016
US

V. Phone/Fax

Practice location:
  • Phone: 406-222-7555
  • Fax:
Mailing address:
  • Phone: 406-222-7555
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number7268
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: