Provider Demographics
NPI:1912909748
Name:BRICKNER, CHARLES D (MD)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:D
Last Name:BRICKNER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 751803
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1803
Mailing Address - Country:US
Mailing Address - Phone:336-718-7777
Mailing Address - Fax:336-718-7744
Practice Address - Street 1:1351 WESTGATE CENTER DR
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-2934
Practice Address - Country:US
Practice Address - Phone:336-718-7777
Practice Address - Fax:336-718-7744
Is Sole Proprietor?:No
Enumeration Date:2005-08-11
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WAMD00039688208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8278962Medicaid
WA8278962Medicaid
WAAB22309Medicare ID - Type Unspecified