Provider Demographics
NPI:1114928132
Name:WIKE, DONNA R (OD)
Entity Type:Individual
Prefix:DR
First Name:DONNA
Middle Name:R
Last Name:WIKE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1950 OLD GALLOWS RD
Mailing Address - Street 2:SUITE 520
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-3990
Mailing Address - Country:US
Mailing Address - Phone:703-847-8899
Mailing Address - Fax:703-991-0514
Practice Address - Street 1:1729 DAVIE AVE
Practice Address - Street 2:
Practice Address - City:STATESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28677-3521
Practice Address - Country:US
Practice Address - Phone:704-873-0524
Practice Address - Fax:704-873-0549
Is Sole Proprietor?:No
Enumeration Date:2005-08-02
Last Update Date:2014-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0929152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC09978OtherBCBS
NC8909978Medicaid
T64831Medicare UPIN
NC246284Medicare ID - Type Unspecified