Provider Demographics
NPI:1114491743
Name:KIMBERLY HICKS M D INC
Entity Type:Organization
Organization Name:KIMBERLY HICKS M D INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:HICKS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:510-517-8005
Mailing Address - Street 1:3317 ELM ST STE 102
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94609-3053
Mailing Address - Country:US
Mailing Address - Phone:510-595-9880
Mailing Address - Fax:510-517-8001
Practice Address - Street 1:3317 ELM ST STE 102
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94609-3053
Practice Address - Country:US
Practice Address - Phone:510-595-9880
Practice Address - Fax:510-595-9881
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-16
Last Update Date:2019-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1972661254Medicaid