Provider Demographics
NPI:1770552671
Name:WICKE, AUTUMN KAY (OD)
Entity type:Individual
Prefix:DR
First Name:AUTUMN
Middle Name:KAY
Last Name:WICKE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1555 BRADY ROAD
Mailing Address - Street 2:
Mailing Address - City:CHESANING
Mailing Address - State:MI
Mailing Address - Zip Code:48616-0355
Mailing Address - Country:US
Mailing Address - Phone:989-845-7050
Mailing Address - Fax:989-845-2036
Practice Address - Street 1:1555 BRADY ROAD
Practice Address - Street 2:
Practice Address - City:CHESANING
Practice Address - State:MI
Practice Address - Zip Code:48616-0355
Practice Address - Country:US
Practice Address - Phone:989-845-7050
Practice Address - Fax:989-845-2036
Is Sole Proprietor?:No
Enumeration Date:2006-03-15
Last Update Date:2009-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901004333152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI944824022Medicaid
MIN17900004Medicare ID - Type Unspecified
MIV07174Medicare UPIN
MI944824022Medicaid