Healthcare Provider Details

I. General information

NPI: 1760456958
Provider Name (Legal Business Name): WILLET J HICKMAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/14/2006
Last Update Date: 04/03/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

520 DOUGLAS BLVD
TYLER TX
75702-8307
US

IV. Provider business mailing address

PO BOX 5500
TYLER TX
75712-5500
US

V. Phone/Fax

Practice location:
  • Phone: 903-593-1721
  • Fax: 903-510-8724
Mailing address:
  • Phone: 903-324-6450
  • Fax: 903-593-7852

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberE3707
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: