Provider Demographics
NPI:1053460204
Name:HICKS, ANTHONY M (MD)
Entity Type:Individual
Prefix:DR
First Name:ANTHONY
Middle Name:M
Last Name:HICKS
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 1:4100 DUVAL RD STE 4-202
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78759-4278
Mailing Address - Country:US
Mailing Address - Phone:512-832-9686
Mailing Address - Fax:
Practice Address - Street 1:4100 DUVAL RD STE 4-202
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78759-4278
Practice Address - Country:US
Practice Address - Phone:512-832-9686
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ4853173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes173000000XOther Service ProvidersLegal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXF82196Medicare UPIN