Provider Demographics
NPI:1609819606
Name:DICK, DAVID WESLEY (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:WESLEY
Last Name:DICK
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 1:6920 POINTE INVERNESS WAY STE 200
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-7934
Mailing Address - Country:US
Mailing Address - Phone:604-793-5132
Mailing Address - Fax:
Practice Address - Street 1:1210 PROVIDENT DRIVE
Practice Address - Street 2:STE B
Practice Address - City:WARSAW
Practice Address - State:IN
Practice Address - Zip Code:46580
Practice Address - Country:US
Practice Address - Phone:574-268-4300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2021-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01044051A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200047340Medicaid
G11555Medicare UPIN
IN200047340Medicaid
134670BMedicare PIN
453220HHMedicare PIN