Provider Demographics
NPI:1720164353
Name:WICK, MITCHELL ALBERT (DO)
Entity Type:Individual
Prefix:DR
First Name:MITCHELL
Middle Name:ALBERT
Last Name:WICK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:914 S CHIPPEWA CIR
Mailing Address - Street 2:
Mailing Address - City:BOYNTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33436
Mailing Address - Country:US
Mailing Address - Phone:984-612-5034
Mailing Address - Fax:
Practice Address - Street 1:3795 WEST BOYNTON BEACH BLVD
Practice Address - Street 2:WALK IN FAMILY MEDICINE CENTER
Practice Address - City:BOYNTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:33436
Practice Address - Country:US
Practice Address - Phone:561-736-2001
Practice Address - Fax:561-736-2002
Is Sole Proprietor?:No
Enumeration Date:2006-10-27
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL054327207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLOS4327OtherLICENSE
BW5617189OtherDEA
FLOS4327OtherLICENSE
E51931Medicare UPIN