Healthcare Provider Details

I. General information

NPI: 1457382335
Provider Name (Legal Business Name): TOMMY L. HICKS, M.D., INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/06/2006
Last Update Date: 12/07/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23521 PASEO DE VALENCIA STE 108
LAGUNA HILLS CA
92653-3137
US

IV. Provider business mailing address

23521 PASEO DE VALENCIA STE 108
LAGUNA HILLS CA
92653-3137
US

V. Phone/Fax

Practice location:
  • Phone: 949-588-7262
  • Fax: 949-588-7260
Mailing address:
  • Phone: 949-588-7262
  • Fax: 949-588-7260

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberG48888
License Number StateCA

VIII. Authorized Official

Name: TOMMY LEONARD HICKS
Title or Position: PHYSICIAN
Credential: M.D.
Phone: 949-588-7262