| Doctor Name: | DR. OTTO WILLIAM WICKSTROM |
| NPI Number: | 1487826939 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | M.D. |
| License Number: | 01065381A |
| Business Practice Address: | 583 S Clarizz Blvd Bloomington, IN - 474015515 |
| Business Phone Number: | 8123332663 |
| Business Fax Number: | 8123499206 |
| Mailing Address: | 583 S Clarizz Blvd, BLOOMINGTON |
| State: | IN |
| Postal Code: | 474015515 |
| Phone Number: | |
| Fax Number: | |
| NPI Enumeration Date: | 03/25/2008 |
| NPI Last Update Date: | 01/05/2016 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 174400000X |
| License Number: | 01065381A |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | IN |
| Taxonomy Type: | Other Service Providers |
| Taxonomy Classification: | Specialist |
| Taxonomy Specialization: | |
| Taxonomy Definition: | An individual educated and trained in an applied knowledge discipline used in the performance of work at a level requiring knowledge and skills beyond or apart from that provided by a general education or liberal arts degree. |