Provider Demographics
NPI:1629381926
Name:HICKS, ROSALYND E (MD)
Entity Type:Individual
Prefix:
First Name:ROSALYND
Middle Name:E
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 1:19017 GAULT ST UNIT 102
Mailing Address - Street 2:
Mailing Address - City:RESEDA
Mailing Address - State:CA
Mailing Address - Zip Code:91335-3945
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:19017 GAULT ST UNIT 102
Practice Address - Street 2:
Practice Address - City:RESEDA
Practice Address - State:CA
Practice Address - Zip Code:91335-3945
Practice Address - Country:US
Practice Address - Phone:818-300-1376
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-15
Last Update Date:2010-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA062356207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA062356OtherLICENSE
CAA062356OtherLICENSE