Provider Demographics
NPI:1376543546
Name:HICKERSON, STEVEN L (MD)
Entity Type:Individual
Prefix:DR
First Name:STEVEN
Middle Name:L
Last Name:HICKERSON
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:PO BOX 131629
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75713-1629
Mailing Address - Country:US
Mailing Address - Phone:903-592-4473
Mailing Address - Fax:903-592-4474
Practice Address - Street 1:935 S BAXTER AVE
Practice Address - Street 2:STE 103
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-2245
Practice Address - Country:US
Practice Address - Phone:903-592-4473
Practice Address - Fax:903-592-4474
Is Sole Proprietor?:No
Enumeration Date:2005-07-28
Last Update Date:2007-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH6286207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX133135708Medicaid
TX133135708Medicaid
TX8A5912Medicare PIN