Provider Demographics
NPI:1154346591
Name:WICKS, MICHAEL DAVID (MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:DAVID
Last Name:WICKS
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 1:347 FAIRVIEW ST
Mailing Address - Street 2:
Mailing Address - City:SILVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97381-1916
Mailing Address - Country:US
Mailing Address - Phone:503-873-8341
Mailing Address - Fax:503-873-2328
Practice Address - Street 1:347 FAIRVIEW ST
Practice Address - Street 2:
Practice Address - City:SILVERTON
Practice Address - State:OR
Practice Address - Zip Code:97381-1916
Practice Address - Country:US
Practice Address - Phone:503-873-8341
Practice Address - Fax:503-873-2328
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-13
Last Update Date:2010-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD09070207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine