Provider Demographics
NPI:1538134010
Name:WIKERT, GARY ALLAN (MD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:ALLAN
Last Name:WIKERT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29 TAYLOR AVE
Mailing Address - Street 2:SUITE 210
Mailing Address - City:CROSSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38555-4527
Mailing Address - Country:US
Mailing Address - Phone:931-707-5313
Mailing Address - Fax:931-484-4856
Practice Address - Street 1:29 TAYLOR AVE
Practice Address - Street 2:SUITE 210
Practice Address - City:CROSSVILLE
Practice Address - State:TN
Practice Address - Zip Code:38555-4527
Practice Address - Country:US
Practice Address - Phone:931-707-5313
Practice Address - Fax:931-484-4856
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-20
Last Update Date:2011-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD0000034776174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3735040Medicaid
TNPOO906801OtherMCR RR
TN3735040Medicare PIN
TN3735040Medicaid