Healthcare Provider Details

I. General information

NPI: 1912914714
Provider Name (Legal Business Name): ROBERT W ZICKLER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2006
Last Update Date: 04/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2555 COURT DR STE 200
GASTONIA NC
28054-2134
US

IV. Provider business mailing address

2555 COURT DR STE 200
GASTONIA NC
28054-2134
US

V. Phone/Fax

Practice location:
  • Phone: 704-867-2141
  • Fax: 704-867-2308
Mailing address:
  • Phone: 704-867-2141
  • Fax: 704-867-2308

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number01067280A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number2012-00441
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: