Provider Demographics
NPI:1184622573
Name:WICKWIRE, BRIAN M (MD)
Entity type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:M
Last Name:WICKWIRE
Suffix:
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 1689
Mailing Address - Street 2:
Mailing Address - City:PHARR
Mailing Address - State:TX
Mailing Address - Zip Code:78577-1630
Mailing Address - Country:US
Mailing Address - Phone:956-787-0787
Mailing Address - Fax:956-787-2021
Practice Address - Street 1:600 N GARZA ST STE A
Practice Address - Street 2:
Practice Address - City:RIO GRANDE CITY
Practice Address - State:TX
Practice Address - Zip Code:78582
Practice Address - Country:US
Practice Address - Phone:956-487-0846
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-11
Last Update Date:2018-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL3524207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX154778801Medicaid
TX8727K7Medicare ID - Type UnspecifiedMEDICARE NUMBER
TXH49306Medicare UPIN