Provider Demographics
NPI:1235524976
Name:WICE, MITCHELL BENJAMIN (MD)
Entity Type:Individual
Prefix:DR
First Name:MITCHELL
Middle Name:BENJAMIN
Last Name:WICE
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 1:110 ELM STREET
Mailing Address - Street 2:ATTN CREDENTIALING
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02903-4626
Mailing Address - Country:US
Mailing Address - Phone:401-443-4992
Mailing Address - Fax:401-537-7241
Practice Address - Street 1:593 EDDY ST
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02903-4923
Practice Address - Country:US
Practice Address - Phone:401-444-5248
Practice Address - Fax:401-444-3397
Is Sole Proprietor?:No
Enumeration Date:2015-03-31
Last Update Date:2021-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY293021207RG0300X
390200000X
RIMD17655207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program