Provider Demographics
NPI:1861700189
Name:WICHERT, CHRISTOPHER KARL (DPT)
Entity type:Individual
Prefix:MR
First Name:CHRISTOPHER
Middle Name:KARL
Last Name:WICHERT
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1155 N MAYFAIR RD
Mailing Address - Street 2:SPINE CARE CLINIC
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-3462
Mailing Address - Country:US
Mailing Address - Phone:414-955-7199
Mailing Address - Fax:414-955-0110
Practice Address - Street 1:1155 N MAYFAIR RD
Practice Address - Street 2:SPINE CARE CLINIC
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-3462
Practice Address - Country:US
Practice Address - Phone:414-955-7199
Practice Address - Fax:414-955-0110
Is Sole Proprietor?:No
Enumeration Date:2010-09-21
Last Update Date:2014-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11483-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI859400071OtherMEDICARE
WI1861700189Medicaid