Provider Demographics
NPI:1801917950
Name:WICK, MICHAEL M (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:M
Last Name:WICK
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 1:2995 WOODSIDE RD
Mailing Address - Street 2:STE 400
Mailing Address - City:WOODSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:94062-2446
Mailing Address - Country:US
Mailing Address - Phone:650-845-7711
Mailing Address - Fax:
Practice Address - Street 1:2995 WOODSIDE RD
Practice Address - Street 2:STE 400
Practice Address - City:WOODSIDE
Practice Address - State:CA
Practice Address - Zip Code:94062-2446
Practice Address - Country:US
Practice Address - Phone:650-845-7711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-03
Last Update Date:2022-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA37261207NS0135X
CAG34509207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology