MEDICARE: DR. SUZANNE WICKUM O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	10639TPA	CA
2	152W00000X	Optometrist	5166TG	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1386648731
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SUZANNE WICKUM O.D.

Provider Business Mailing Address
First Line	:	5901 E 7TH ST
Second Line	:
City	:	LONG BEACH
State	:	CA
Zip	:	90822-5201
Country	:	US
Telephone Number	:	562-826-8000
Fax Number	:

Provider Business Practice Location Address
First Line	:	5901 E 7TH ST
Second Line	:
City	:	LONG BEACH
State	:	CA
Zip	:	90822-5201
Country	:	US
Telephone Number	:	562-826-8000
Fax Number	:	562-826-5063

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/13/2005
Last Update Date	:	12/06/2019

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