Provider Demographics
NPI:1104105204
Name:WICHERT, BRENT ALAN (OD)
Entity type:Individual
Prefix:
First Name:BRENT
Middle Name:ALAN
Last Name:WICHERT
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2700 E 30TH AVE
Mailing Address - Street 2:
Mailing Address - City:HUTCHINSON
Mailing Address - State:KS
Mailing Address - Zip Code:67502-1242
Mailing Address - Country:US
Mailing Address - Phone:620-802-0051
Mailing Address - Fax:620-802-0074
Practice Address - Street 1:2700 E 30TH AVE
Practice Address - Street 2:
Practice Address - City:HUTCHINSON
Practice Address - State:KS
Practice Address - Zip Code:67502-1242
Practice Address - Country:US
Practice Address - Phone:620-802-0051
Practice Address - Fax:620-802-0074
Is Sole Proprietor?:No
Enumeration Date:2011-08-08
Last Update Date:2019-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1908152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist