Healthcare Provider Details

I. General information

NPI: 1134113319
Provider Name (Legal Business Name): RUSSELL WAYNE ICKE OD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/02/2005
Last Update Date: 07/28/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7050 E LINCOLN ST
WICHITA KS
67207-2638
US

IV. Provider business mailing address

7050 E LINCOLN ST
WICHITA KS
67207-2638
US

V. Phone/Fax

Practice location:
  • Phone: 316-683-9671
  • Fax: 316-683-0168
Mailing address:
  • Phone: 316-683-9671
  • Fax: 316-683-0168

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number10352
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: