Provider Demographics
NPI:1861598526
Name:WIKHOLM, GARY D (MD)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:D
Last Name:WIKHOLM
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 1:247 W HARVARD BLVD
Mailing Address - Street 2:
Mailing Address - City:SANTA PAULA
Mailing Address - State:CA
Mailing Address - Zip Code:93060-3223
Mailing Address - Country:US
Mailing Address - Phone:805-525-0907
Mailing Address - Fax:805-933-3392
Practice Address - Street 1:247 W HARVARD BLVD
Practice Address - Street 2:
Practice Address - City:SANTA PAULA
Practice Address - State:CA
Practice Address - Zip Code:93060-3223
Practice Address - Country:US
Practice Address - Phone:805-525-0907
Practice Address - Fax:805-933-3392
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA41000207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A410000Medicaid
CAWA41000DMedicare ID - Type Unspecified
CA00A410000Medicaid