Healthcare Provider Details

I. General information

NPI: 1528136975
Provider Name (Legal Business Name): DAWN E. WICKIZER O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/02/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

436 S RANDALL RD
ALGONQUIN IL
60102-9723
US

IV. Provider business mailing address

436 S RANDALL RD
ALGONQUIN IL
60102-9723
US

V. Phone/Fax

Practice location:
  • Phone: 847-658-4242
  • Fax: 847-658-5643
Mailing address:
  • Phone: 847-658-4242
  • Fax: 847-658-5643

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number
License Number StateIL

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: