Provider Demographics
NPI:1811289085
Name:WICKES, DAVID (DC)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:
Last Name:WICKES
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:453 FISHER CT
Mailing Address - Street 2:
Mailing Address - City:SHELTON
Mailing Address - State:CT
Mailing Address - Zip Code:06484-2836
Mailing Address - Country:US
Mailing Address - Phone:503-341-2570
Mailing Address - Fax:
Practice Address - Street 1:453 FISHER CT
Practice Address - Street 2:
Practice Address - City:SHELTON
Practice Address - State:CT
Practice Address - Zip Code:06484-2836
Practice Address - Country:US
Practice Address - Phone:503-341-2570
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-06
Last Update Date:2013-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH00034818111NI0900X
IL038003761111NI0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NI0900XChiropractic ProvidersChiropractorInternist