Provider Demographics
NPI:1033100151
Name:WICKIEWICZ, ROBERT (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:WICKIEWICZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1123
Mailing Address - Street 2:
Mailing Address - City:LATHAM
Mailing Address - State:NY
Mailing Address - Zip Code:12110-0079
Mailing Address - Country:US
Mailing Address - Phone:800-357-4829
Mailing Address - Fax:518-786-1293
Practice Address - Street 1:1301 RIVER ST
Practice Address - Street 2:
Practice Address - City:VALATIE
Practice Address - State:NY
Practice Address - Zip Code:12184-9694
Practice Address - Country:US
Practice Address - Phone:518-748-7736
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1141502085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
B13400Medicare UPIN