Healthcare Provider Details

I. General information

NPI: 1063041473
Provider Name (Legal Business Name): TYLER DANIEL WICKAS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/07/2020
Last Update Date: 07/22/2025
Certification Date: 07/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6002 POINTE WEST BLVD
BRADENTON FL
34209-5531
US

IV. Provider business mailing address

PO BOX 11407
BIRMINGHAM AL
35246-8575
US

V. Phone/Fax

Practice location:
  • Phone: 941-792-2020
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberME162826
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: