Individual
DR. RUSSELL WAYNE ICKE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
OD
Contact information
Practice address
7050 E LINCOLN ST, WICHITA, KS 67207-2638
(316) 683-9671
(316) 683-0168
Mailing address
7050 E LINCOLN ST, WICHITA, KS 67207-2638
(316) 683-9671
(316) 683-0168
Taxonomy
Speciality
Code
Description
License number
State
152W00000X
Optometrist
Primary
10352
KS
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0212690001
MEDICARE DMERC REGION D
—
05
—
10090970A
—
KS
01
—
826580253
RAILROAD MEDICARE
—
Enumeration date
09/02/2005
Last updated
07/28/2010
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