Healthcare Provider Details

I. General information

NPI: 1972571198
Provider Name (Legal Business Name): CLIFTON C HICKMAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2006
Last Update Date: 12/28/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

161 WADSWORTH DR
RICHMOND VA
23236-4500
US

IV. Provider business mailing address

161 WADSWORTH DR
RICHMOND VA
23236-4500
US

V. Phone/Fax

Practice location:
  • Phone: 804-484-3702
  • Fax: 804-320-6462
Mailing address:
  • Phone: 804-484-3702
  • Fax: 804-320-6462

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number0101033277
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: