Provider Demographics
NPI:1710975412
Name:WICK, BRUCE CHARLES (OD, PHD)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:CHARLES
Last Name:WICK
Suffix:
Gender:M
Credentials:OD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13615 BELLAIRE BLVD
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77083-1714
Mailing Address - Country:US
Mailing Address - Phone:281-933-3446
Mailing Address - Fax:281-933-6865
Practice Address - Street 1:13615 BELLAIRE BLVD
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77083-1714
Practice Address - Country:US
Practice Address - Phone:281-933-3446
Practice Address - Fax:281-933-6865
Is Sole Proprietor?:No
Enumeration Date:2005-10-07
Last Update Date:2008-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX4042TG152WV0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX4743680001OtherCIGNA GOV SERVICES NUMBER
TX4743680001OtherCIGNA GOV SERVICES NUMBER
TXT66657Medicare UPIN
TX82712EMedicare PIN