1720164353 NPI number — DR. MITCHELL ALBERT WICK DO

Table of content: DR. MITCHELL ALBERT WICK DO (NPI 1720164353)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720164353 NPI number — DR. MITCHELL ALBERT WICK DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WICK
Provider First Name:
MITCHELL
Provider Middle Name:
ALBERT
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DO
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1720164353
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
914 S CHIPPEWA CIR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOYNTON BEACH
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33436
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
984-612-5034
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3795 WEST BOYNTON BEACH BLVD
Provider Second Line Business Practice Location Address:
WALK IN FAMILY MEDICINE CENTER
Provider Business Practice Location Address City Name:
BOYNTON BEACH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33436
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
561-736-2001
Provider Business Practice Location Address Fax Number:
561-736-2002
Provider Enumeration Date:
10/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  054327 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: OS4327 . This is a "LICENSE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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