Provider Demographics
NPI:1790866069
Name:WICHNOSKI, DAVID JOSEPH (OD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:JOSEPH
Last Name:WICHNOSKI
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:7615 COLONY RD
Mailing Address - Street 2:STE 105
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28226
Mailing Address - Country:US
Mailing Address - Phone:704-543-9000
Mailing Address - Fax:704-543-9002
Practice Address - Street 1:7615 COLONY RD
Practice Address - Street 2:STE 105
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28226
Practice Address - Country:US
Practice Address - Phone:704-543-9000
Practice Address - Fax:704-543-9002
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2024-09-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC1632152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89090SLMedicaid
NC89090SLMedicaid
NCU66590Medicare UPIN