Provider Demographics
NPI:1164442729
Name:HICKS, TAMMIE FAULK (OD)
Entity Type:Individual
Prefix:
First Name:TAMMIE
Middle Name:FAULK
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:PO BOX 4346
Mailing Address - Street 2:DEPT 521
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77210
Mailing Address - Country:US
Mailing Address - Phone:713-580-2500
Mailing Address - Fax:
Practice Address - Street 1:14079 FM 2920
Practice Address - Street 2:
Practice Address - City:TOMBALL
Practice Address - State:TX
Practice Address - Zip Code:77377-5502
Practice Address - Country:US
Practice Address - Phone:346-701-4035
Practice Address - Fax:281-701-4035
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2015-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX5128TG152W00000X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXU69522Medicare UPIN