Provider Demographics
NPI:1942287115
Name:WICKS, MARK S (MD PHD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:S
Last Name:WICKS
Suffix:
Gender:M
Credentials:MD PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 E OGDEN AVE
Mailing Address - Street 2:STE 202
Mailing Address - City:WESTMONT
Mailing Address - State:IL
Mailing Address - Zip Code:60559-5569
Mailing Address - Country:US
Mailing Address - Phone:630-789-9785
Mailing Address - Fax:630-789-9798
Practice Address - Street 1:700 E OGDEN AVE
Practice Address - Street 2:STE 202
Practice Address - City:WESTMONT
Practice Address - State:IL
Practice Address - Zip Code:60559-5569
Practice Address - Country:US
Practice Address - Phone:630-789-9785
Practice Address - Fax:630-789-9798
Is Sole Proprietor?:No
Enumeration Date:2005-12-28
Last Update Date:2011-09-08
Deactivation Date:2007-01-23
Deactivation Code:
Reactivation Date:2011-07-20
Provider Licenses
StateLicense IDTaxonomies
IL036050774207RC0200X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
C42513Medicare UPIN