MEDICARE: DR. DEAN J WICKEL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2086S0129X	Vascular Surgery Physician	29653	WV
2	2086S0129X	Vascular Surgery Physician	010701869B	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1811991763
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DEAN J WICKEL

Provider Business Mailing Address
First Line	:	PO BOX 642
Second Line	:
City	:	PROSPECT
State	:	KY
Zip	:	40059-0642
Country	:	US
Telephone Number	:	502-472-6629
Fax Number	:

Provider Business Practice Location Address
First Line	:	502 CABELA DR
Second Line	:
City	:	TRIADELPHIA
State	:	WV
Zip	:	26059-1044
Country	:	US
Telephone Number	:	304-285-1996
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/09/2005
Last Update Date	:	04/21/2022

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Directions to “ DR. DEAN J WICKEL ” Practice Location

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