Provider Demographics
NPI:1881883338
Name:WIKE, DOUGLAS M (OD)
Entity type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:M
Last Name:WIKE
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 1:2023 W MCDERMOTT DR STE 290
Mailing Address - Street 2:
Mailing Address - City:ALLEN
Mailing Address - State:TX
Mailing Address - Zip Code:75013-4678
Mailing Address - Country:US
Mailing Address - Phone:972-649-4441
Mailing Address - Fax:972-649-4410
Practice Address - Street 1:2023 W MCDERMOTT DR STE 290
Practice Address - Street 2:
Practice Address - City:ALLEN
Practice Address - State:TX
Practice Address - Zip Code:75013-4678
Practice Address - Country:US
Practice Address - Phone:972-649-4441
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-22
Last Update Date:2023-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX5285TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP00274868OtherMEDICARE RAILROAD PTAN
TX019228802Medicaid
TXP00274868OtherMEDICARE RAILROAD PTAN
TX019228801Medicaid
TX1118500001Medicare NSC