Provider Demographics
NPI:1417909938
Name:HICKSON, CHARLENE J (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLENE
Middle Name:J
Last Name:HICKSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1218 S PUEBLO BLVD
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81005-1593
Mailing Address - Country:US
Mailing Address - Phone:719-566-1277
Mailing Address - Fax:719-566-1257
Practice Address - Street 1:1218 S PUEBLO BLVD
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81005-1593
Practice Address - Country:US
Practice Address - Phone:719-566-1277
Practice Address - Fax:719-566-1257
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2022-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO39435207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO50255843Medicaid
COCOA100061Medicare PIN
CO50255843Medicaid