Provider Demographics
NPI:1710408117
Name:BOYD R WICKIZER MD LLC
Entity Type:Organization
Organization Name:BOYD R WICKIZER MD LLC
Other - Org Name:DR. WICKIZER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BOYD
Authorized Official - Middle Name:R
Authorized Official - Last Name:WICKIZER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:804-938-0264
Mailing Address - Street 1:PO BOX 446
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23113-0446
Mailing Address - Country:US
Mailing Address - Phone:804-938-0264
Mailing Address - Fax:
Practice Address - Street 1:2802 OTTERDALE RD
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23112-5408
Practice Address - Country:US
Practice Address - Phone:804-938-0264
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-06
Last Update Date:2017-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101047692261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1750330353Medicaid