Healthcare Provider Details

I. General information

NPI: 1689607210
Provider Name (Legal Business Name): MICHAEL D WICKS, MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/08/2006
Last Update Date: 08/16/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

347 FAIRVIEW ST
SILVERTON OR
97381-1916
US

IV. Provider business mailing address

347 FAIRVIEW ST
SILVERTON OR
97381-1916
US

V. Phone/Fax

Practice location:
  • Phone: 503-873-8341
  • Fax: 503-873-2328
Mailing address:
  • Phone: 503-873-8341
  • Fax: 503-873-2328

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD09070
License Number StateOR

VIII. Authorized Official

Name: DR. MICHAEL DAVID WICKS
Title or Position: OWNER
Credential: M.D.
Phone: 503-873-8341