Provider Demographics
NPI:1033189071
Name:WICKLESS, LARRY A (MD)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:A
Last Name:WICKLESS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28080 GRAND RIVER AVE
Mailing Address - Street 2:SUITE 306
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48336-5966
Mailing Address - Country:US
Mailing Address - Phone:248-471-8982
Mailing Address - Fax:248-426-7350
Practice Address - Street 1:28080 GRAND RIVER AVE
Practice Address - Street 2:SUITE 306
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48336-5966
Practice Address - Country:US
Practice Address - Phone:248-471-8982
Practice Address - Fax:248-426-7350
Is Sole Proprietor?:No
Enumeration Date:2006-01-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101005865207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
B47677Medicare UPIN