Basic Information
| Provider Information | |||||||||
| NPI: | 1720164353 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WICK | ||||||||
| FirstName: | MITCHELL | ||||||||
| MiddleName: | ALBERT | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 914 S CHIPPEWA CIR | ||||||||
| Address2: | |||||||||
| City: | BOYNTON BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33436 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9846125034 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3795 WEST BOYNTON BEACH BLVD | ||||||||
| Address2: | WALK IN FAMILY MEDICINE CENTER | ||||||||
| City: | BOYNTON BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33436 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5617362001 | ||||||||
| FaxNumber: | 5617362002 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/27/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 054327 | FL | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | OS4327 | 01 | FL | LICENSE | OTHER | BW5617189 | 01 | DEA | OTHER |