Provider Demographics
NPI:1437147030
Name:HICKMANN, MARTHA A (MD)
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:A
Last Name:HICKMANN
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 1:3025 GOVERNORS PLACE BLVD
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45409
Mailing Address - Country:US
Mailing Address - Phone:937-293-5567
Mailing Address - Fax:937-293-5568
Practice Address - Street 1:3025 GOVERNORS PLACE BLVD
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45409
Practice Address - Country:US
Practice Address - Phone:937-293-5567
Practice Address - Fax:937-293-5568
Is Sole Proprietor?:No
Enumeration Date:2005-10-10
Last Update Date:2011-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-06-0161207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2088646Medicaid
E66423Medicare UPIN