MEDICARE: PETER G HICKOX M.D.

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	207V00000X	Obstetrics & Gynecology Physician	G86782	CA
2	174400000X	Specialist	G86782	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	911803606	OTHER	CA	TAX ID

General Provider Information

NPI Number	:	1962401810
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PETER G HICKOX M.D.

Provider Business Mailing Address
First Line	:	420 W ACACIA ST
Second Line	:	SUITE 11
City	:	STOCKTON
State	:	CA
Zip	:	95203-2441
Country	:	US
Telephone Number	:	209-948-4098
Fax Number	:	209-948-2334

Provider Business Practice Location Address
First Line	:	420 W ACACIA ST
Second Line	:	SUTIE 11
City	:	STOCKTON
State	:	CA
Zip	:	95203-2441
Country	:	US
Telephone Number	:	209-948-4098
Fax Number	:	209-948-2334

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

Provider Enumeration Date	:	07/21/2005
Last Update Date	:	08/21/2013

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