Karl Theodore Wickstrom, M.D.

Primary specialty

Diagnostic Radiology PhysicianTaxonomy code 2085R0202X

License

21726 Issued in AZ

Practice address

790 Gail Gardner Way
Prescott, AZ 86305-2337

Phone

(928) 776-9900

Fax

(928) 776-1444

NPI assigned

Jun 10, 2005

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Other identifiers 1

Other names 1

• Ted Wickstrom Other name

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Enrolled

Credentials

Doctor of Medicine

Practice roles

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Medwise PC

  • Diagnostic Radiology Physician
  • Prescott, AZ
  • NPI 1427006253
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1118361600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1362009600000",
    "number": "1669476123",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "790 GAIL GARDNER WAY",
            "city": "PRESCOTT",
            "state": "AZ",
            "postal_code": "863052337",
            "telephone_number": "928-776-9900",
            "fax_number": "928-776-1444"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "790 GAIL GARDNER WAY",
            "city": "PRESCOTT",
            "state": "AZ",
            "postal_code": "863052337",
            "telephone_number": "928-776-9900",
            "fax_number": "928-776-1444"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WICKSTROM",
        "first_name": "KARL",
        "middle_name": "THEODORE",
        "credential": "M.D.",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2005-06-10",
        "last_updated": "2013-02-28",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "2085R0202X",
            "taxonomy_group": "",
            "desc": "Radiology, Diagnostic Radiology",
            "state": "AZ",
            "license": "21726",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "446866",
            "state": "AZ"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "first_name": "TED",
            "last_name": "WICKSTROM",
            "credential": "M.D.",
            "code": "5",
            "type": "Other Name"
        }
    ]
}

• Shannon Whitlock, PAC
• Whitney James, MD, PC
• Ronald F Whitney, M.D.
• Wholemind Healing Pathways
• Barbara Kathryn Wich, M.D.
• Hanna Magdalena Wiesner, LMT
• Amanda J Wikan, RD, LD
• Joan L Wilburg-Bourne
• Quinton Wiggins Wilder, LMT
• Sondra Wilkening, MS, LPC

• Diagnostic Radiology Physician in Prescott, AZ
• Providers in Prescott, AZ by specialty
• Diagnostic Radiology Physician in Arizona

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 28, 2013; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.