| Dr. Wickizer | |
|
2802 Otterdale Rd Midlothian VA 23112-5408 | |
| (804) 938-0264 | |
| Not Available |
| Full Name | Dr. Wickizer |
|---|---|
| Speciality | Clinic/Center |
| Location | 2802 Otterdale Rd, Midlothian, Virginia |
| Authorized Official Name and Position | Boyd R Wickizer (PRESIDENT) |
| Authorized Official Contact | 8049380264 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Dr. Wickizer Po Box 446 Midlothian VA 23113-0446 Ph: (804) 938-0264 | Dr. Wickizer 2802 Otterdale Rd Midlothian VA 23112-5408 Ph: (804) 938-0264 |
| NPI Number | 1710408117 |
|---|---|
| Provider Enumeration Date | 07/06/2017 |
| Last Update Date | 07/06/2017 |
| Medicare PECOS PAC ID | 1456624972 |
|---|---|
| Medicare Enrollment ID | O20170906000318 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1710408117 | NPI | - | NPPES |
| 1750330353 | Medicaid | VA |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 261QM1300X | Clinic/center - Multi-specialty | 0101047692 (Virginia) | Primary |
| Provider Name | Boyd R Wickizer |
|---|---|
| Provider Type | Practitioner - Emergency Medicine |
| Provider Identifiers | NPI Number: 1750330353 PECOS PAC ID: 7416029590 Enrollment ID: I20081028000321 |
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