Provider Demographics
NPI:1134110422
Name:FICK, BRUCE DUANE (MD)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:DUANE
Last Name:FICK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:5201 WILLOW SPRINGS RD
Mailing Address - Street 2:SUITE 450
Mailing Address - City:LA GRANGE HIGHLANDS
Mailing Address - State:IL
Mailing Address - Zip Code:60525-6537
Mailing Address - Country:US
Mailing Address - Phone:708-354-2008
Mailing Address - Fax:708-354-2092
Practice Address - Street 1:5201 WILLOW SPRINGS RD
Practice Address - Street 2:SUITE 450
Practice Address - City:LA GRANGE HIGHLANDS
Practice Address - State:IL
Practice Address - Zip Code:60525-6537
Practice Address - Country:US
Practice Address - Phone:708-354-2008
Practice Address - Fax:708-354-2092
Is Sole Proprietor?:No
Enumeration Date:2005-11-04
Last Update Date:2009-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036040370207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
C41474Medicare UPIN
460550Medicare ID - Type Unspecified
ILIL1337002Medicare PIN