Healthcare Provider Details

I. General information

NPI: 1942204284
Provider Name (Legal Business Name): JOHN B HICKS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2005
Last Update Date: 08/05/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1213 56TH ST
MERIDIAN MS
39305-1447
US

IV. Provider business mailing address

1213 56TH ST
MERIDIAN MS
39305-1447
US

V. Phone/Fax

Practice location:
  • Phone: 601-483-7812
  • Fax: 601-482-4269
Mailing address:
  • Phone: 601-483-7812
  • Fax: 601-482-4269

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number09618
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: