Provider Demographics
NPI:1104968510
Name:RICHARD W WIKE O D PA
Entity type:Organization
Organization Name:RICHARD W WIKE O D PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:W
Authorized Official - Last Name:WIKE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:479-855-0009
Mailing Address - Street 1:2829 BELLA VISTA WAY
Mailing Address - Street 2:
Mailing Address - City:BELLA VISTA
Mailing Address - State:AR
Mailing Address - Zip Code:72714-3709
Mailing Address - Country:US
Mailing Address - Phone:479-855-0009
Mailing Address - Fax:479-876-7105
Practice Address - Street 1:2829 BELLA VISTA WAY
Practice Address - Street 2:
Practice Address - City:BELLA VISTA
Practice Address - State:AR
Practice Address - Zip Code:72714-3709
Practice Address - Country:US
Practice Address - Phone:479-855-0009
Practice Address - Fax:479-876-7105
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-13
Last Update Date:2010-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARAR2256152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR159680722Medicaid
AR159680722Medicaid
AR490135F377Medicare ID - Type Unspecified