Provider Demographics
NPI:1093247769
Name:WICKS, IVY (MD)
Entity Type:Individual
Prefix:
First Name:IVY
Middle Name:
Last Name:WICKS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:12070 OLD LINE CTR STE 302
Mailing Address - Street 2:
Mailing Address - City:WALDORF
Mailing Address - State:MD
Mailing Address - Zip Code:20602-2567
Mailing Address - Country:US
Mailing Address - Phone:301-645-6667
Mailing Address - Fax:301-870-9722
Practice Address - Street 1:12070 OLD LINE CTR STE 302
Practice Address - Street 2:
Practice Address - City:WALDORF
Practice Address - State:MD
Practice Address - Zip Code:20602-2567
Practice Address - Country:US
Practice Address - Phone:301-645-6667
Practice Address - Fax:301-870-9722
Is Sole Proprietor?:No
Enumeration Date:2017-03-31
Last Update Date:2023-07-31
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MDD0091620207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine