Healthcare Provider Details

I. General information

NPI: 1376744565
Provider Name (Legal Business Name): ALFRED K HICKS JR. D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/29/2007
Last Update Date: 07/01/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

512 SAYBROOK RD STE 100
MIDDLETOWN CT
06457-4788
US

IV. Provider business mailing address

512 SAYBROOK RD STE 100
MIDDLETOWN CT
06457-4788
US

V. Phone/Fax

Practice location:
  • Phone: 860-347-7636
  • Fax:
Mailing address:
  • Phone: 860-347-7636
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number02959
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number240996
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number54330
License Number StateCT
# 4
Primary TaxonomyN
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License Number02959
License Number StateKY
# 5
Primary TaxonomyY
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License Number54330
License Number StateCT
# 6
Primary TaxonomyN
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License Number16410
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: