Provider Demographics
NPI:1184714115
Name:PERLICK, WYNN A (DPM)
Entity type:Individual
Prefix:DR
First Name:WYNN
Middle Name:A
Last Name:PERLICK
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:111 WILLARD ST
Mailing Address - Street 2:SUITE 2F
Mailing Address - City:QUINCY
Mailing Address - State:MA
Mailing Address - Zip Code:02169-1200
Mailing Address - Country:US
Mailing Address - Phone:617-773-2313
Mailing Address - Fax:617-328-3861
Practice Address - Street 1:111 WILLARD ST
Practice Address - Street 2:SUITE 2F
Practice Address - City:QUINCY
Practice Address - State:MA
Practice Address - Zip Code:02169-1200
Practice Address - Country:US
Practice Address - Phone:617-773-2313
Practice Address - Fax:617-328-3861
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2011-10-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA2053213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
042297845OtherGREAT WEST HEALTH CARE
042297845OtherPHCS/MULTI-PLAN
042297845OtherGIC/UNICARE
002053OtherTUFTS MEDICARE PREFERRED
1215062OtherFALLON
MAY71014OtherBLUE CROSS
043376631OtherGIC
043376631OtherPHCS
043376631OtherPRUDENTIAL
33917OtherHARVARD PILGRIM
002053OtherTUFTS
0620074OtherAETNA
27 00004OtherUNITED HEALTH CARE
334257OtherHARVARD PILGRIM
042297845OtherTRICARE
042297845OtherHCVM/FIRST HEALTH/COVENTY
5297190OtherAETNA
MAY77182OtherBLUE CROSS
1194680001Medicare NSC
0620074OtherAETNA
U59427Medicare UPIN