Provider Demographics
NPI:1083695803
Name:WICKHAM, MATTHEW DAVID (OD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:DAVID
Last Name:WICKHAM
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3013 WINGHAVEN BLVD
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:MO
Mailing Address - Zip Code:63368-3600
Mailing Address - Country:US
Mailing Address - Phone:636-561-3937
Mailing Address - Fax:636-561-4068
Practice Address - Street 1:3013 WINGHAVEN BLVD
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:MO
Practice Address - Zip Code:63368-3600
Practice Address - Country:US
Practice Address - Phone:636-561-3937
Practice Address - Fax:636-561-4068
Is Sole Proprietor?:No
Enumeration Date:2005-11-09
Last Update Date:2012-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOT03134152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO258094555Medicare ID - Type Unspecified
U75625Medicare UPIN