Provider Demographics
NPI:1992706048
Name:WICKERSHAM, ELIZABETH A (MD)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:A
Last Name:WICKERSHAM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4345 W MEMORIAL RD
Mailing Address - Street 2:SUITE 110
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73134-1702
Mailing Address - Country:US
Mailing Address - Phone:405-418-7000
Mailing Address - Fax:405-418-7099
Practice Address - Street 1:4345 W MEMORIAL RD
Practice Address - Street 2:SUITE 110
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73134-1702
Practice Address - Country:US
Practice Address - Phone:405-418-7000
Practice Address - Fax:405-418-7099
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-10
Last Update Date:2023-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK20273207QH0002X, 208VP0000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QH0002XAllopathic & Osteopathic PhysiciansFamily MedicineHospice and Palliative Medicine
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200036870AMedicaid
OK241405909Medicare ID - Type Unspecified
OK200036870AMedicaid