Provider Demographics
NPI:1154493500
Name:HICKS, MELINDA LEE (OD)
Entity Type:Individual
Prefix:DR
First Name:MELINDA
Middle Name:LEE
Last Name:HICKS
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2737 CROSSROADS BLVD
Mailing Address - Street 2:
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81506-3954
Mailing Address - Country:US
Mailing Address - Phone:970-243-9681
Mailing Address - Fax:970-243-9155
Practice Address - Street 1:2737 CROSSROADS BLVD
Practice Address - Street 2:
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81506-3954
Practice Address - Country:US
Practice Address - Phone:970-243-9681
Practice Address - Fax:970-243-9155
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2021-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1453152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO08145302Medicaid
CO410046449OtherMETRA-HEALTH RR MDCR
CO4285550001OtherDMERC
CO410046449OtherMETRA-HEALTH RR MDCR
COT93093Medicare UPIN
CO410046449OtherMETRA-HEALTH RR MDCR