Provider Demographics
NPI:1104861806
Name:WICKAS, LOUIS J III (MD)
Entity type:Individual
Prefix:
First Name:LOUIS
Middle Name:J
Last Name:WICKAS
Suffix:III
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 1:90 JACKSON PIKE
Mailing Address - Street 2:
Mailing Address - City:GALLIPOLIS
Mailing Address - State:OH
Mailing Address - Zip Code:45631-1560
Mailing Address - Country:US
Mailing Address - Phone:740-446-5227
Mailing Address - Fax:740-441-8058
Practice Address - Street 1:100 JACKSON PIKE
Practice Address - Street 2:
Practice Address - City:GALLIPOLIS
Practice Address - State:OH
Practice Address - Zip Code:45631-1560
Practice Address - Country:US
Practice Address - Phone:740-446-5238
Practice Address - Fax:740-441-8058
Is Sole Proprietor?:No
Enumeration Date:2006-06-17
Last Update Date:2021-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV20922207L00000X
OH35-08-1701207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0787180OtherMOLINA MEDICAID #
OH0787180Medicaid
OH000000193689OtherUNISON MEDICAID #
000000261323OtherANTHEM BCBS
WV0058894000Medicaid
000605261OtherMOUNTAIN STATE BCBS
OH050091556OtherRR MEDICARE
000000261323OtherANTHEM BCBS
E55548Medicare UPIN