Provider Demographics
NPI:1538267471
Name:WICKSTROM-HILL, DALE (DO)
Entity type:Individual
Prefix:DR
First Name:DALE
Middle Name:
Last Name:WICKSTROM-HILL
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 198096
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-8096
Mailing Address - Country:US
Mailing Address - Phone:352-867-8898
Mailing Address - Fax:352-732-6282
Practice Address - Street 1:200 AVENUE F NE
Practice Address - Street 2:
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33881-4131
Practice Address - Country:US
Practice Address - Phone:352-867-8898
Practice Address - Fax:352-732-6282
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-21
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS0006374207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL80933OtherBLUE CROSS BLUE SHIELD
FL003632900Medicaid
FL80933OtherBLUE CROSS BLUE SHIELD
FL269252000Medicaid