Provider Demographics
NPI:1972571313
Name:TICK, DAVID BRUCE (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:BRUCE
Last Name:TICK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:216 GREEN BAY RD STE 109
Mailing Address - Street 2:
Mailing Address - City:THIENSVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53092-1625
Mailing Address - Country:US
Mailing Address - Phone:262-241-5414
Mailing Address - Fax:262-672-4046
Practice Address - Street 1:216 GREEN BAY RD STE 109
Practice Address - Street 2:
Practice Address - City:THIENSVILLE
Practice Address - State:WI
Practice Address - Zip Code:53092
Practice Address - Country:US
Practice Address - Phone:262-241-5414
Practice Address - Fax:262-241-5425
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-10
Last Update Date:2018-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA34022208000000X
WI34022207SG0201X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
No207SG0201XAllopathic & Osteopathic PhysiciansMedical GeneticsClinical Genetics (M.D.)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI110174900OtherRAILROAD MEDICARE
WI33540257OtherCHAMPUS
WI31891200Medicaid
WI050577505014OtherBLUE CROSS/BLUE SHIELD