Healthcare Provider Details

I. General information

NPI: 1033189071
Provider Name (Legal Business Name): LARRY A WICKLESS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/24/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28080 GRAND RIVER AVE SUITE 306
FARMINGTON HILLS MI
48336-5966
US

IV. Provider business mailing address

28080 GRAND RIVER AVE SUITE 306
FARMINGTON HILLS MI
48336-5966
US

V. Phone/Fax

Practice location:
  • Phone: 248-471-8982
  • Fax: 248-426-7350
Mailing address:
  • Phone: 248-471-8982
  • Fax: 248-426-7350

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number5101005865
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: