Healthcare Provider Details

I. General information

NPI: 1194983346
Provider Name (Legal Business Name): RYAN WALTER HICK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2008
Last Update Date: 07/29/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1355 RIVER BEND DR
DALLAS TX
75247-4915
US

IV. Provider business mailing address

1355 RIVER BEND DR
DALLAS TX
75247-4915
US

V. Phone/Fax

Practice location:
  • Phone: 214-237-1640
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberMD435635
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License NumberMD435635
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberN3082
License Number StateTX
# 4
Primary TaxonomyY
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License NumberN3082
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: