Provider Demographics
NPI:1316385115
Name:HICKS, MICHAEL DAVID (DO)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:DAVID
Last Name:HICKS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4504 STARKEY RD STE 200
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24018-8535
Mailing Address - Country:US
Mailing Address - Phone:540-772-4344
Mailing Address - Fax:
Practice Address - Street 1:1900 ELECTRIC RD
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:VA
Practice Address - Zip Code:24153
Practice Address - Country:US
Practice Address - Phone:540-776-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-13
Last Update Date:2018-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0102205163207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology