Provider Demographics
NPI:1801174537
Name:WICKS, COLTON DALE (OD)
Entity type:Individual
Prefix:DR
First Name:COLTON
Middle Name:DALE
Last Name:WICKS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 EAST PLZ
Mailing Address - Street 2:
Mailing Address - City:PARIS
Mailing Address - State:TX
Mailing Address - Zip Code:75460-5841
Mailing Address - Country:US
Mailing Address - Phone:903-784-6649
Mailing Address - Fax:
Practice Address - Street 1:15 EAST PLZ
Practice Address - Street 2:
Practice Address - City:PARIS
Practice Address - State:TX
Practice Address - Zip Code:75460-5841
Practice Address - Country:US
Practice Address - Phone:903-784-6649
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-29
Last Update Date:2011-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX7734T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist