Healthcare Provider Details

I. General information

NPI: 1982698783
Provider Name (Legal Business Name): DANIEL J WICKERT M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/07/2005
Last Update Date: 10/04/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3920 ST FRANCIS WAY SUITE 110
LAFAYETTE IN
47905-4917
US

IV. Provider business mailing address

3920 ST FRANCIS WAY SUITE 110
LAFAYETTE IN
47905-4917
US

V. Phone/Fax

Practice location:
  • Phone: 765-428-5800
  • Fax: 765-428-5802
Mailing address:
  • Phone: 765-428-5800
  • Fax: 765-428-5802

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number01034216A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: