Provider Demographics
NPI:1780026708
Name:WICKS, ABBY BROTHERTON (OD)
Entity Type:Individual
Prefix:
First Name:ABBY
Middle Name:BROTHERTON
Last Name:WICKS
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:ABBY
Other - Middle Name:CHRISTINE
Other - Last Name:BROTHERTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:PO BOX 844658
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-4658
Mailing Address - Country:US
Mailing Address - Phone:254-724-2111
Mailing Address - Fax:
Practice Address - Street 1:201 E CENTRAL TEXAS EXPY
Practice Address - Street 2:
Practice Address - City:HARKER HEIGHTS
Practice Address - State:TX
Practice Address - Zip Code:76548-1887
Practice Address - Country:US
Practice Address - Phone:254-953-7650
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-18
Last Update Date:2022-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV008047152W00000X
TX9679T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist