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General NPI Number Information
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NPI Number | 1134113319
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Entity Type | Individual
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Provider Name | RUSSELL WAYNE ICKE OD
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Gender | Male
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Dates
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Enumeration Date | 09/02/2005
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Last Update Date | 07/28/2010
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Provider Practice Location Address
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Address Line | 7050 E LINCOLN ST
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City | WICHITA
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State | KS
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Zip | 67207-2638
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Country | US
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Telephone | 316-683-9671
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Fax | 316-683-0168
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Provider Business Mailing Address
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Address Line | 7050 E LINCOLN ST
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City | WICHITA
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State | KS
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Zip | 67207-2638
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Country | US
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Telephone | 316-683-9671
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Fax | 316-683-0168
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 10352
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License Number State | KS
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