1548681406 NPI number — DAVID WICHNOSKI OD PA

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548681406 NPI number — DAVID WICHNOSKI OD PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DAVID WICHNOSKI OD PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
SPECTRUM EYE CARE
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1548681406
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/19/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7615 COLONY RD
Provider Second Line Business Mailing Address:
SUITE 105
Provider Business Mailing Address City Name:
CHARLOTTE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28226-5018
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-543-9000
Provider Business Mailing Address Fax Number:
704-543-9002

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
119 LANDING DR
Provider Second Line Business Practice Location Address:
STE 105
Provider Business Practice Location Address City Name:
MOORESVILLE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28117
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-817-4600
Provider Business Practice Location Address Fax Number:
704-817-4601
Provider Enumeration Date:
12/19/2013

Additional Information

Authorized Official

Authorized Official Last Name:
WICHNOSKI
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
J
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
704-543-9000

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 89090SL , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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