Provider Demographics
NPI:1295827327
Name:WICKS, CHARLES M (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:M
Last Name:WICKS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:LAHEY CLINIC
Mailing Address - Street 2:41 MALL ROAD
Mailing Address - City:BURLINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:01805-0001
Mailing Address - Country:US
Mailing Address - Phone:978-374-1010
Mailing Address - Fax:978-556-0568
Practice Address - Street 1:233 LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:HAVERHILL
Practice Address - State:MA
Practice Address - Zip Code:01830-6738
Practice Address - Country:US
Practice Address - Phone:978-374-1010
Practice Address - Fax:978-556-0568
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2010-06-09
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Provider Licenses
StateLicense IDTaxonomies
MA49128207RP1001X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0161772Medicaid
MAA66447Medicare UPIN
MA0161772Medicaid