Provider Demographics
NPI:1730182841
Name:WICKER, MITCHELL JR (MD)
Entity type:Individual
Prefix:
First Name:MITCHELL
Middle Name:
Last Name:WICKER
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 719
Mailing Address - Street 2:
Mailing Address - City:HAZARD
Mailing Address - State:KY
Mailing Address - Zip Code:41702-0719
Mailing Address - Country:US
Mailing Address - Phone:606-439-1316
Mailing Address - Fax:606-435-0752
Practice Address - Street 1:271 E MAIN ST
Practice Address - Street 2:
Practice Address - City:HAZARD
Practice Address - State:KY
Practice Address - Zip Code:41701-1939
Practice Address - Country:US
Practice Address - Phone:606-439-1316
Practice Address - Fax:606-435-0752
Is Sole Proprietor?:No
Enumeration Date:2005-05-23
Last Update Date:2010-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY21790207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64217904Medicaid
KY371401Medicare ID - Type Unspecified
KY64217904Medicaid