MEDICARE: DR. BRYAN MARTIN WICK M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084P0800X	Psychiatry Physician	A95308	CA

General Provider Information

NPI Number	:	1700099611
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BRYAN MARTIN WICK M.D.

Provider Business Mailing Address
First Line	:	25654 LANE ST
Second Line	:
City	:	LOMA LINDA
State	:	CA
Zip	:	92354-2415
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	11374 MOUNTAIN VIEW AVE
Second Line	:	DOVER BUILDING, SUITE C
City	:	LOMA LINDA
State	:	CA
Zip	:	92354-3815
Country	:	US
Telephone Number	:	909-558-6094
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/07/2007
Last Update Date	:	11/29/2021

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