Provider Demographics
NPI:1164806048
Name:KICK, PRESTON JAMES (DO)
Entity type:Individual
Prefix:DR
First Name:PRESTON
Middle Name:JAMES
Last Name:KICK
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 1:605 WEST STATE STREET
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:MEDIA
Mailing Address - State:PA
Mailing Address - Zip Code:19063-2620
Mailing Address - Country:US
Mailing Address - Phone:301-752-8529
Mailing Address - Fax:
Practice Address - Street 1:605 WEST STATE STREET
Practice Address - Street 2:
Practice Address - City:MEDIA
Practice Address - State:PA
Practice Address - Zip Code:19063-2620
Practice Address - Country:US
Practice Address - Phone:301-752-8529
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-10
Last Update Date:2024-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS022514207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine