Provider Demographics
NPI:1215026489
Name:WICKES, ROBERT VINCENT (OD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:VINCENT
Last Name:WICKES
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 1:118 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MONTESANO
Mailing Address - State:WA
Mailing Address - Zip Code:98563-3709
Mailing Address - Country:US
Mailing Address - Phone:360-249-3485
Mailing Address - Fax:360-249-2747
Practice Address - Street 1:118 S MAIN ST
Practice Address - Street 2:
Practice Address - City:MONTESANO
Practice Address - State:WA
Practice Address - Zip Code:98563-3709
Practice Address - Country:US
Practice Address - Phone:360-249-3485
Practice Address - Fax:360-249-2747
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-12
Last Update Date:2007-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA1272152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2012995Medicaid
WA2012995Medicaid
WAG000800645Medicare PIN
WAT10363Medicare UPIN