Provider Demographics
NPI:1356300776
Name:HICKSON, RENEE B (MD)
Entity Type:Individual
Prefix:
First Name:RENEE
Middle Name:B
Last Name:HICKSON
Suffix:
Gender:F
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:PO BOX 746063
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-6063
Mailing Address - Country:US
Mailing Address - Phone:312-733-9730
Mailing Address - Fax:312-929-0373
Practice Address - Street 1:1004 SURREY ST
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70501
Practice Address - Country:US
Practice Address - Phone:337-456-6768
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2021-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.022772207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1493040Medicaid
LA1493040Medicaid
LA5A586Medicare PIN