Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 208800000X | Urologist | 27814 | FL |
NPI | 1013979186 |
---|---|
Provider Name | Dr. Mark Brent Wickman |
First Address | North Miami, FL 33161-4964 |
Second Address | North Miami, FL 33161-4964 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 04/04/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
D58608 | (02) | FL |