MEDICARE: CRAIG HICKS OD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	2807-035	WI

General Provider Information

NPI Number	:	1568519734
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CRAIG HICKS OD

Provider Business Mailing Address
First Line	:	11103 WEST AVE
Second Line	:	STE 6
City	:	SAN ANTONIO
State	:	TX
Zip	:	78213-1370
Country	:	US
Telephone Number	:	210-524-6803
Fax Number	:	210-524-6587

Provider Business Practice Location Address
First Line	:	3500 S 27TH ST
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53221-1302
Country	:	US
Telephone Number	:	414-817-9100
Fax Number	:	414-817-9128

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/03/2007
Last Update Date	:	07/08/2007

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