Healthcare Provider Details

I. General information

NPI: 1811991763
Provider Name (Legal Business Name): DR. DEAN J WICKEL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2005
Last Update Date: 04/21/2022
Certification Date: 04/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

502 CABELA DR
TRIADELPHIA WV
26059-1044
US

IV. Provider business mailing address

PO BOX 642
PROSPECT KY
40059-0642
US

V. Phone/Fax

Practice location:
  • Phone: 304-285-1996
  • Fax:
Mailing address:
  • Phone: 502-472-6629
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number29653
License Number StateWV
# 2
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number010701869B
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: