Provider Demographics
NPI:1639116676
Name:HICKLE, RANDALL S (MD)
Entity Type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:S
Last Name:HICKLE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2804 N LOOP 289
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79415-1410
Mailing Address - Country:US
Mailing Address - Phone:806-744-7223
Mailing Address - Fax:806-740-3325
Practice Address - Street 1:2412 50TH ST
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79412-2504
Practice Address - Country:US
Practice Address - Phone:806-744-7223
Practice Address - Fax:806-740-3325
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2013-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH4012207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX130387701Medicaid
TX130387701Medicaid
TXB74528Medicare UPIN