Provider Demographics
NPI:1609372499
Name:WICKMAN, JOHN RHODES (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:RHODES
Last Name:WICKMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1601 TRINITY ST STOP Z0800
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78712-1765
Mailing Address - Country:US
Mailing Address - Phone:512-495-5089
Mailing Address - Fax:
Practice Address - Street 1:1601 TRINITY ST STOP Z0800
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78712-1765
Practice Address - Country:US
Practice Address - Phone:512-495-5089
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-02
Last Update Date:2024-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2023009376207X00000X
TXV2329207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery