Provider Demographics
NPI:1912063900
Name:WICKE, SUSAN HOLLY (MD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:HOLLY
Last Name:WICKE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:
Other - Last Name:WICKE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:112 SWIFT AVE
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27705
Mailing Address - Country:US
Mailing Address - Phone:919-308-6076
Mailing Address - Fax:919-308-6076
Practice Address - Street 1:112 SWIFT AVE
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27705
Practice Address - Country:US
Practice Address - Phone:919-308-6076
Practice Address - Fax:919-308-6076
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-28
Last Update Date:2013-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC366182084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2188551AMedicare ID - Type UnspecifiedMD
NCF58331Medicare UPIN