Provider Demographics
NPI:1184787228
Name:WICKS, ERIC D (MD)
Entity type:Individual
Prefix:DR
First Name:ERIC
Middle Name:D
Last Name:WICKS
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 1:1324 LAKELAND HILLS BLV.D
Mailing Address - Street 2:ATTN: MANAGED CARE DEPT.
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33805
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3030 HARDEN BLVD
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33803
Practice Address - Country:US
Practice Address - Phone:863-687-1250
Practice Address - Fax:863-687-1258
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2022-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH9310111N00000X
FLME118027207XX0005X, 207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
No111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLTRN17578OtherFLORIDA TRN LICENSE
FLCH9310OtherCHIROPRACTIC LICENSE
FLTRN17578OtherFLORIDA TRN LICENSE