Provider Demographics
NPI:1619337532
Name:HICKS, ILZE (MD)
Entity Type:Individual
Prefix:
First Name:ILZE
Middle Name:
Last Name:HICKS
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:PO BOX 551178
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32255-1178
Mailing Address - Country:US
Mailing Address - Phone:804-912-4947
Mailing Address - Fax:
Practice Address - Street 1:5011 GATE PKWY STE 100
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-0830
Practice Address - Country:US
Practice Address - Phone:904-720-8635
Practice Address - Fax:866-380-0827
Is Sole Proprietor?:No
Enumeration Date:2016-03-04
Last Update Date:2024-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME124762208VP0000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL112624200Medicaid