Provider Demographics
NPI:1972578672
Name:WICKERN, GREGORY MATHEW (MD)
Entity type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:MATHEW
Last Name:WICKERN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:800 FALLS AVE
Mailing Address - Street 2:SUITE #2
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-3366
Mailing Address - Country:US
Mailing Address - Phone:208-734-6091
Mailing Address - Fax:208-734-4654
Practice Address - Street 1:1502 LOCUST ST N STE 600
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-4164
Practice Address - Country:US
Practice Address - Phone:208-734-6091
Practice Address - Fax:208-734-4654
Is Sole Proprietor?:No
Enumeration Date:2006-02-17
Last Update Date:2020-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV13018207K00000X
UT6578473-1205207K00000X
IDM-10495207KA0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207KA0200XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyAllergy
No207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology