Provider Demographics
NPI:1376744565
Name:HICKS, ALFRED K JR (DO)
Entity Type:Individual
Prefix:DR
First Name:ALFRED
Middle Name:K
Last Name:HICKS
Suffix:JR
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 1:512 SAYBROOK RD
Mailing Address - Street 2:STE 100
Mailing Address - City:MIDDLETOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06457-4788
Mailing Address - Country:US
Mailing Address - Phone:860-347-7636
Mailing Address - Fax:
Practice Address - Street 1:512 SAYBROOK RD
Practice Address - Street 2:STE 100
Practice Address - City:MIDDLETOWN
Practice Address - State:CT
Practice Address - Zip Code:06457-4788
Practice Address - Country:US
Practice Address - Phone:860-347-7636
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-29
Last Update Date:2015-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY02959207XS0117X, 207X00000X
NY240996207X00000X
CT54330207XS0117X, 207X00000X
NH16410207XS0117X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the Spine
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000584574OtherANTHEM (SPINE INSTITUTE)
KY0235851Medicare PIN
KY0605948Medicare PIN
KY000000586301OtherANTHEM (UNIV ORTHO ASSOC)
KY00533178Medicare PIN