Healthcare Provider Details

I. General information

NPI: 1679700959
Provider Name (Legal Business Name): LINDSAY HICKERSON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2009
Last Update Date: 08/13/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1350 HICKORY ST
MELBOURNE FL
32901
US

IV. Provider business mailing address

3300 S FISKE BLVD
ROCKLEDGE FL
32955-4306
US

V. Phone/Fax

Practice location:
  • Phone: 321-434-1401
  • Fax: 321-434-1667
Mailing address:
  • Phone: 321-434-1981
  • Fax: 321-951-7408

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207XX0801X
TaxonomyOrthopaedic Trauma Physician
License Number31400
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code207XX0801X
TaxonomyOrthopaedic Trauma Physician
License Number273286
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code207XX0801X
TaxonomyOrthopaedic Trauma Physician
License NumberME140535
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: