MEDICARE: WILLIAM JAMES WICKWIRE MD

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	207N00000X	Dermatology Physician	G65083	CA

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
2	WG65083E	OTHER	CA	PTAN

General Provider Information

NPI Number	:	1699779660
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	WILLIAM JAMES WICKWIRE MD

Provider Business Mailing Address
First Line	:	520 N PROSPECT AVE
Second Line	:	STE 302
City	:	REDONDO BEACH
State	:	CA
Zip	:	90277-3043
Country	:	US
Telephone Number	:	310-798-1515
Fax Number	:	310-798-3131

Provider Business Practice Location Address
First Line	:	520 N PROSPECT AVE
Second Line	:	STE 302
City	:	REDONDO BEACH
State	:	CA
Zip	:	90277-3043
Country	:	US
Telephone Number	:	310-798-1515
Fax Number	:	310-798-3131

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

Provider Enumeration Date	:	06/08/2005
Last Update Date	:	02/21/2014

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