Provider Demographics
NPI:1992893051
Name:WICKE, CHRISTOPHER GORDON (LO)
Entity type:Individual
Prefix:MR
First Name:CHRISTOPHER
Middle Name:GORDON
Last Name:WICKE
Suffix:
Gender:M
Credentials:LO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 WESTER COURT
Mailing Address - Street 2:
Mailing Address - City:NEWINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06111
Mailing Address - Country:US
Mailing Address - Phone:860-667-0199
Mailing Address - Fax:
Practice Address - Street 1:7 WEBSTER SQUARE RD
Practice Address - Street 2:
Practice Address - City:BERLIN
Practice Address - State:CT
Practice Address - Zip Code:06037-2326
Practice Address - Country:US
Practice Address - Phone:860-828-6684
Practice Address - Fax:860-828-1467
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1380156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician