Provider Demographics
NPI:1205835717
Name:HICKEY, SAMUEL JR (MD)
Entity Type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:
Last Name:HICKEY
Suffix:JR
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 1:42440 PELICAN PROFESSIONAL PARK
Mailing Address - Street 2:
Mailing Address - City:HAMMOND
Mailing Address - State:LA
Mailing Address - Zip Code:70403-2403
Mailing Address - Country:US
Mailing Address - Phone:985-542-4950
Mailing Address - Fax:985-542-6089
Practice Address - Street 1:42440 PELICAN PROFESSIONAL PARK
Practice Address - Street 2:
Practice Address - City:HAMMOND
Practice Address - State:LA
Practice Address - Zip Code:70403-2403
Practice Address - Country:US
Practice Address - Phone:985-542-4950
Practice Address - Fax:985-542-6089
Is Sole Proprietor?:No
Enumeration Date:2005-07-18
Last Update Date:2011-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA024236208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1489786Medicaid