Provider Demographics
NPI:1497056386
Name:H. RANDALL HICKS, M.D. INC, H RANDALL HICKS PRES
Entity Type:Organization
Organization Name:H. RANDALL HICKS, M.D. INC, H RANDALL HICKS PRES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT & CEO
Authorized Official - Prefix:
Authorized Official - First Name:H. RANDALL
Authorized Official - Middle Name:
Authorized Official - Last Name:HICKS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:619-298-7135
Mailing Address - Street 1:4060 FOURTH AVE
Mailing Address - Street 2:SUITE 615
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-2116
Mailing Address - Country:US
Mailing Address - Phone:619-298-7135
Mailing Address - Fax:858-874-8837
Practice Address - Street 1:4060 FOURTH AVE
Practice Address - Street 2:SUITE 615
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-2116
Practice Address - Country:US
Practice Address - Phone:619-298-7135
Practice Address - Fax:858-874-8837
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-08
Last Update Date:2014-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG474392084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA92724Medicare UPIN