Provider Demographics
NPI:1326054073
Name:HICKS, TODD L (MD)
Entity Type:Individual
Prefix:
First Name:TODD
Middle Name:L
Last Name:HICKS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2300 MIAMI VALLEY DR
Mailing Address - Street 2:STE 380
Mailing Address - City:CENTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45459-1294
Mailing Address - Country:US
Mailing Address - Phone:937-396-8001
Mailing Address - Fax:937-396-8003
Practice Address - Street 1:580 LINCOLN PARK BLVD
Practice Address - Street 2:STE 300
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45429-3474
Practice Address - Country:US
Practice Address - Phone:937-396-8001
Practice Address - Fax:937-396-8003
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2019-10-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OH35-08-5868208600000X
OH35.0858682086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2665174Medicaid
OH2665174Medicaid