Provider Demographics
NPI:1841263134
Name:WICKENS, MARSHALL (DO)
Entity type:Individual
Prefix:DR
First Name:MARSHALL
Middle Name:
Last Name:WICKENS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:207 S CHESTNUT ST UNIT B
Mailing Address - Street 2:
Mailing Address - City:REED CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49677-1205
Mailing Address - Country:US
Mailing Address - Phone:231-832-9488
Mailing Address - Fax:231-832-9348
Practice Address - Street 1:207 S CHESTNUT ST UNIT B
Practice Address - Street 2:
Practice Address - City:REED CITY
Practice Address - State:MI
Practice Address - Zip Code:49677-1205
Practice Address - Country:US
Practice Address - Phone:231-832-9488
Practice Address - Fax:231-832-9348
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-08
Last Update Date:2014-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101011160207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4592518Medicaid
MI4592518Medicaid
P00216957Medicare PIN
F76001124Medicare PIN