Healthcare Provider Details

I. General information

NPI: 1427378561
Provider Name (Legal Business Name): PATRICE FREDERIC JOEL HICKS DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2010
Last Update Date: 03/05/2025
Certification Date: 03/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5500 CAMPANILE DR
SAN DIEGO CA
92182-4701
US

IV. Provider business mailing address

5500 CAMPANILE DR
SAN DIEGO CA
92182-4701
US

V. Phone/Fax

Practice location:
  • Phone: 619-594-4325
  • Fax:
Mailing address:
  • Phone: 619-594-4325
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberQ3380
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number5994
License Number StateOK
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberE-14613
License Number StateAR
# 4
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number16276
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: