Healthcare Provider Details

I. General information

NPI: 1275238594
Provider Name (Legal Business Name): JOHNATHAN DANIEL HICKS DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/04/2023
Last Update Date: 08/03/2026
Certification Date: 08/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

222 MEDICAL CIR
MOREHEAD KY
40351-1179
US

IV. Provider business mailing address

222 MEDICAL CIR
MOREHEAD KY
40351-1179
US

V. Phone/Fax

Practice location:
  • Phone: 606-783-6500
  • Fax: 606-783-6904
Mailing address:
  • Phone: 606-783-6500
  • Fax: 606-783-6904

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number06407
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: