Provider Demographics
NPI:1518967793
Name:HICKHAM, MICHAEL J
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:J
Last Name:HICKHAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3019 N ARNOULT RD
Mailing Address - Street 2:
Mailing Address - City:METAIRIE
Mailing Address - State:LA
Mailing Address - Zip Code:70002-4714
Mailing Address - Country:US
Mailing Address - Phone:504-889-5335
Mailing Address - Fax:504-702-1922
Practice Address - Street 1:3019 N ARNOULT RD
Practice Address - Street 2:
Practice Address - City:METAIRIE
Practice Address - State:LA
Practice Address - Zip Code:70002-4714
Practice Address - Country:US
Practice Address - Phone:504-889-5335
Practice Address - Fax:504-889-5451
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-28
Last Update Date:2023-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA10820R174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1442828Medicaid
LA1480002Medicaid
LAG66486Medicare UPIN
LA5A305Medicare ID - Type Unspecified
LA5CA72Medicare ID - Type UnspecifiedGROUP