Provider Demographics
NPI:1891795092
Name:WICK, JEFFREY STEPHEN (MD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:STEPHEN
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 1:8200 STOCKDALE HWY
Mailing Address - Street 2:STE M10-357
Mailing Address - City:BAKERSFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93311-1091
Mailing Address - Country:US
Mailing Address - Phone:661-374-5457
Mailing Address - Fax:661-410-8685
Practice Address - Street 1:5001 COMMERCE DR
Practice Address - Street 2:
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93309-0648
Practice Address - Country:US
Practice Address - Phone:661-374-5457
Practice Address - Fax:661-410-8685
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-28
Last Update Date:2017-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG74695208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ447038Medicaid
CACA185274Medicare PIN
AZ64258Medicare PIN