Provider Demographics
NPI:1811991763
Name:WICKEL, DEAN J
Entity type:Individual
Prefix:DR
First Name:DEAN
Middle Name:J
Last Name:WICKEL
Suffix:
Gender:M
Credentials:
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 642
Mailing Address - Street 2:
Mailing Address - City:PROSPECT
Mailing Address - State:KY
Mailing Address - Zip Code:40059-0642
Mailing Address - Country:US
Mailing Address - Phone:502-472-6629
Mailing Address - Fax:
Practice Address - Street 1:502 CABELA DR
Practice Address - Street 2:
Practice Address - City:TRIADELPHIA
Practice Address - State:WV
Practice Address - Zip Code:26059-1044
Practice Address - Country:US
Practice Address - Phone:304-285-1996
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-09
Last Update Date:2022-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV296532086S0129X
IN010701869B2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201039920Medicaid
INM45226032Medicare PIN