Provider Demographics
NPI:1386643757
Name:WIKE, PEGGY LYNN (OD)
Entity Type:Individual
Prefix:DR
First Name:PEGGY
Middle Name:LYNN
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:PO BOX 359
Mailing Address - Street 2:
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28115-0359
Mailing Address - Country:US
Mailing Address - Phone:704-664-5406
Mailing Address - Fax:704-663-6498
Practice Address - Street 1:622 N MAIN ST
Practice Address - Street 2:
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28115-2312
Practice Address - Country:US
Practice Address - Phone:704-664-5406
Practice Address - Fax:704-663-6498
Is Sole Proprietor?:No
Enumeration Date:2005-07-19
Last Update Date:2011-04-19
Deactivation Date:2006-03-20
Deactivation Code:
Reactivation Date:2006-04-05
Provider Licenses
StateLicense IDTaxonomies
NC1130152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7909969Medicaid
NCT65031Medicare UPIN
NC246501CMedicare PIN
NC0606540001Medicare NSC