Provider Demographics
NPI:1477626232
Name:HICKS, WALTER LYNN (MD)
Entity Type:Individual
Prefix:
First Name:WALTER
Middle Name:LYNN
Last Name:HICKS
Suffix:
Gender:M
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 1213
Mailing Address - Street 2:
Mailing Address - City:BRUNSWICK
Mailing Address - State:GA
Mailing Address - Zip Code:31521-1213
Mailing Address - Country:US
Mailing Address - Phone:912-466-5800
Mailing Address - Fax:912-265-1524
Practice Address - Street 1:3400 PARKWOOD DR
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:GA
Practice Address - Zip Code:31520-4755
Practice Address - Country:US
Practice Address - Phone:912-466-5800
Practice Address - Fax:912-265-1524
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-17
Last Update Date:2016-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA018902207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
D45644Medicare UPIN