Provider Demographics
NPI:1306848148
Name:WICKERHAM, DONALD LAWRENCE (MD)
Entity type:Individual
Prefix:
First Name:DONALD
Middle Name:LAWRENCE
Last Name:WICKERHAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:D LAWRENCE
Other - Middle Name:
Other - Last Name:WICKERHAM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:320 E NORTH AVE
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15212-4756
Mailing Address - Country:US
Mailing Address - Phone:412-359-3336
Mailing Address - Fax:412-359-6263
Practice Address - Street 1:320 E NORTH AVE
Practice Address - Street 2:
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15212-4756
Practice Address - Country:US
Practice Address - Phone:412-359-3336
Practice Address - Fax:412-359-6263
Is Sole Proprietor?:No
Enumeration Date:2005-08-11
Last Update Date:2020-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD026049E2086X0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086X0206XAllopathic & Osteopathic PhysiciansSurgerySurgical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810008593Medicaid
PA000864191Medicaid
110943Medicare PIN
PA000864191Medicaid
PAB36848Medicare UPIN
PA910000287Medicare PIN