Provider Demographics
NPI:1093962896
Name:WIKIERA, RICHARD HENRY (DO)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:HENRY
Last Name:WIKIERA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:6810 STATE ROUTE 162 STE 100
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62062-8560
Mailing Address - Country:US
Mailing Address - Phone:618-288-3616
Mailing Address - Fax:618-288-3647
Practice Address - Street 1:6810 STATE ROUTE 162 STE 100
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:IL
Practice Address - Zip Code:62062-8560
Practice Address - Country:US
Practice Address - Phone:618-288-3616
Practice Address - Fax:618-288-3647
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-22
Last Update Date:2020-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36133309208600000X
MO2008016721208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty