Provider Demographics
NPI:1598818627
Name:HICKS, DAVID T (OD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:T
Last Name:HICKS
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:313 N DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:HARVARD
Mailing Address - State:IL
Mailing Address - Zip Code:60033-3060
Mailing Address - Country:US
Mailing Address - Phone:815-943-6635
Mailing Address - Fax:815-943-6740
Practice Address - Street 1:313 N DIVISION ST
Practice Address - Street 2:
Practice Address - City:HARVARD
Practice Address - State:IL
Practice Address - Zip Code:60033-3060
Practice Address - Country:US
Practice Address - Phone:815-943-6635
Practice Address - Fax:815-943-6740
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL211523Medicare ID - Type Unspecified