Healthcare Provider Details

I. General information

NPI: 1619140027
Provider Name (Legal Business Name): JOHN ROBERT HICKOX MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/07/2008
Last Update Date: 05/24/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

303 MULBERRY ST NE
ALBUQUERQUE NM
87106-4739
US

IV. Provider business mailing address

303 MULBERRY ST NE
ALBUQUERQUE NM
87106-4739
US

V. Phone/Fax

Practice location:
  • Phone: 505-243-9739
  • Fax: 505-842-0650
Mailing address:
  • Phone: 505-243-9739
  • Fax: 505-842-0650

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberMD2013-0203
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: