Provider Demographics
NPI:1033209606
Name:HICKERSON, WILLIAM LESLIE (MD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:LESLIE
Last Name:HICKERSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:890 MADISON AVE
Mailing Address - Street 2:SUITE TG032
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38103-3409
Mailing Address - Country:US
Mailing Address - Phone:901-448-2579
Mailing Address - Fax:901-448-2602
Practice Address - Street 1:890 MADISON AVE
Practice Address - Street 2:SUITE TG032
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38103-3409
Practice Address - Country:US
Practice Address - Phone:901-448-2579
Practice Address - Fax:901-448-2602
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2018-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-43742086S0102X, 2086S0122X
TN127092086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
No2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00154377Medicaid
MO1033209606Medicaid
AR111048001Medicaid
AL177555Medicaid
TN3001590Medicaid
GA003179306AMedicaid