Healthcare Provider Details

I. General information

NPI: 1396843942
Provider Name (Legal Business Name): BRYAN HICKS MD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 04/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5349 SW COLLEGE RD STE 2
OCALA FL
34474-5717
US

IV. Provider business mailing address

5349 SW COLLEGE RD STE 2
OCALA FL
34474-5717
US

V. Phone/Fax

Practice location:
  • Phone: 352-368-5858
  • Fax: 352-368-2044
Mailing address:
  • Phone: 352-368-5858
  • Fax: 352-368-2044

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberME47583
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License NumberME47583
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License NumberME47583
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code207NI0002X
TaxonomyClinical & Laboratory Dermatological Immunology Physician
License NumberME47583
License Number StateFL
# 5
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License NumberME47583
License Number StateFL

VIII. Authorized Official

Name: DR. BRYAN CRAIG HICKS
Title or Position: PRESIDENT
Credential: MD
Phone: 352-368-5858