Provider Demographics
NPI:1255328886
Name:HICKS, HEATHER L (MD)
Entity Type:Individual
Prefix:DR
First Name:HEATHER
Middle Name:L
Last Name:HICKS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:L
Other - Last Name:HUGHES
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:4020 W FLORIDA AVE
Mailing Address - Street 2:
Mailing Address - City:HEMET
Mailing Address - State:CA
Mailing Address - Zip Code:92545-5279
Mailing Address - Country:US
Mailing Address - Phone:951-925-9565
Mailing Address - Fax:951-766-7621
Practice Address - Street 1:4020 W FLORIDA AVE
Practice Address - Street 2:
Practice Address - City:HEMET
Practice Address - State:CA
Practice Address - Zip Code:92545-5279
Practice Address - Country:US
Practice Address - Phone:951-925-9565
Practice Address - Fax:951-766-7621
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-29
Last Update Date:2011-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC54166207Q00000X
ND9891207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND13420Medicaid
ND25524Medicare ID - Type Unspecified
H79768Medicare UPIN