Provider Demographics
NPI:1649775388
Name:WICHERN, COLTER REID (MD, MS)
Entity type:Individual
Prefix:DR
First Name:COLTER
Middle Name:REID
Last Name:WICHERN
Suffix:
Gender:M
Credentials:MD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:960 16TH ST STE 304
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OR
Mailing Address - Zip Code:97477-4175
Mailing Address - Country:US
Mailing Address - Phone:541-744-6172
Mailing Address - Fax:
Practice Address - Street 1:960 16TH ST STE 304
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OR
Practice Address - Zip Code:97477-4175
Practice Address - Country:US
Practice Address - Phone:541-744-6172
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-26
Last Update Date:2025-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD205017207RI0011X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology