Provider Demographics
NPI:1528034204
Name:WICK, PAUL H (MD)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:H
Last Name:WICK
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:PO BOX 9817
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75711-2817
Mailing Address - Country:US
Mailing Address - Phone:903-561-1840
Mailing Address - Fax:903-561-4140
Practice Address - Street 1:1909 RICKETY LN
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75703-1702
Practice Address - Country:US
Practice Address - Phone:903-561-1840
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-23
Last Update Date:2012-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXC91832084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX102801102Medicaid
TX102801102Medicaid
TX613684Medicare PIN
C23458Medicare UPIN