Provider Demographics
NPI:1871803031
Name:DONNA R WIKE, O.D., P.A
Entity type:Organization
Organization Name:DONNA R WIKE, O.D., P.A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:R
Authorized Official - Last Name:WIKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-873-1423
Mailing Address - Street 1:1721 C EAST BROAD ST.
Mailing Address - Street 2:
Mailing Address - City:STATESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28625-4345
Mailing Address - Country:US
Mailing Address - Phone:704-873-1423
Mailing Address - Fax:704-873-1424
Practice Address - Street 1:1721 C EAST BROAD ST.
Practice Address - Street 2:
Practice Address - City:STATESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28625-4345
Practice Address - Country:US
Practice Address - Phone:704-873-1423
Practice Address - Fax:704-873-1424
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-20
Last Update Date:2010-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC929152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8909978Medicaid
NC8909978Medicaid