Healthcare Provider Details

I. General information

NPI: 1225416936
Provider Name (Legal Business Name): BRIAN WICKERS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/13/2015
Last Update Date: 04/30/2026
Certification Date: 04/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14540 OLD SAINT AUGUSTINE RD STE 2571
JACKSONVILLE FL
32258-7420
US

IV. Provider business mailing address

14540 OLD SAINT AUGUSTINE RD STE 2571
JACKSONVILLE FL
32258-7420
US

V. Phone/Fax

Practice location:
  • Phone: 904-886-2251
  • Fax: 904-886-7151
Mailing address:
  • Phone: 904-886-2251
  • Fax: 904-886-7151

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberME180656
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: