Provider Demographics
NPI:1669491973
Name:WICKER, ROBERT T JR (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:T
Last Name:WICKER
Suffix:JR
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:PO BOX 19305
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28219-9305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:16455 STATESVILLE RD
Practice Address - Street 2:STE 480
Practice Address - City:HUNTERSVILLE
Practice Address - State:NC
Practice Address - Zip Code:28078-7135
Practice Address - Country:US
Practice Address - Phone:704-896-3370
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9500768207V00000X, 207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCN00764Medicaid
NC1669491973Medicaid
NC8987310Medicaid
G-14849Medicare UPIN
SCN00764Medicaid
NC2214319EMedicare PIN
NC2214319AMedicare PIN