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General NPI Number Information
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NPI Number | 1356635239
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Entity Type | Organization
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Legal Business Name | THOMAS R. WIKSTROM, MD, PA
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Dates
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Enumeration Date | 06/08/2011
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Last Update Date | 01/27/2012
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Provider Practice Location Address
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Address Line | 6817 SOUTHPOINT PKWY SUITE 2503
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City | JACKSONVILLE
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State | FL
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Zip | 32216-6282
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Country | US
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Telephone | 904-396-0425
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Fax | 904-396-0448
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Provider Business Mailing Address
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Address Line | 6817 SOUTHPOINT PKWY SUITE 2503
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City | JACKSONVILLE
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State | FL
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Zip | 32216-6282
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Country | US
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Telephone | 904-396-0425
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Fax | 904-396-0448
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Authorized Official
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Title or Position | PSYCHIATRIST/OWNER
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Name | DR. THOMAS R. WIKSTROM
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Credential | MD
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Telephone | 904-396-0425
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number | ME52161
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License Number State | FL
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