Provider Demographics
NPI:1982698783
Name:WICKERT, DANIEL J (MD)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:J
Last Name:WICKERT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3920 ST FRANCIS WAY
Mailing Address - Street 2:SUITE 110
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47905-4917
Mailing Address - Country:US
Mailing Address - Phone:765-428-5800
Mailing Address - Fax:765-428-5802
Practice Address - Street 1:3920 ST FRANCIS WAY
Practice Address - Street 2:SUITE 110
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47905-4917
Practice Address - Country:US
Practice Address - Phone:765-428-5800
Practice Address - Fax:765-428-5802
Is Sole Proprietor?:No
Enumeration Date:2005-09-07
Last Update Date:2011-10-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN01034216A207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100232110Medicaid
163450BMedicare PIN
B29524Medicare UPIN
234340IMedicare PIN