Provider Demographics
NPI:1104893650
Name:WICKERSHAM, CORNELIUS W (MD)
Entity type:Individual
Prefix:
First Name:CORNELIUS
Middle Name:W
Last Name:WICKERSHAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:11811 N TATUM BLVD
Mailing Address - Street 2:SUITE 3031
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85028-1614
Mailing Address - Country:US
Mailing Address - Phone:602-317-6874
Mailing Address - Fax:602-953-7767
Practice Address - Street 1:49 LEAVENWORTH ST
Practice Address - Street 2:SUITE 200
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06702-2115
Practice Address - Country:US
Practice Address - Phone:602-317-6874
Practice Address - Fax:602-953-7767
Is Sole Proprietor?:No
Enumeration Date:2006-03-03
Last Update Date:2007-10-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CT013709207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine