Healthcare Provider Details

I. General information

NPI: 1326054073
Provider Name (Legal Business Name): TODD L HICKS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2006
Last Update Date: 10/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

580 LINCOLN PARK BLVD STE 300
DAYTON OH
45429-3474
US

IV. Provider business mailing address

2300 MIAMI VALLEY DR STE 380
CENTERVILLE OH
45459-1294
US

V. Phone/Fax

Practice location:
  • Phone: 937-396-8001
  • Fax: 937-396-8003
Mailing address:
  • Phone: 937-396-8001
  • Fax: 937-396-8003

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number35-08-5868
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number35.085868
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: