Provider Demographics
NPI:1306822457
Name:HICKS, PAUL C (MD)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:C
Last Name:HICKS
Suffix:
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 1:1395 NW 167TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33169-5710
Mailing Address - Country:US
Mailing Address - Phone:305-628-6117
Mailing Address - Fax:
Practice Address - Street 1:50 N. WILSON ROAD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43204
Practice Address - Country:US
Practice Address - Phone:614-702-7915
Practice Address - Fax:614-965-6534
Is Sole Proprietor?:No
Enumeration Date:2005-12-21
Last Update Date:2019-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO37022207Q00000X
OH35.122335207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH01370220Medicaid
AZP00685830OtherRAILROAD MEDICARE
CO01370220Medicaid
AZ392564Medicaid
AZZ124541Medicare PIN
AZP00685830OtherRAILROAD MEDICARE
OH01370220Medicaid