Provider Demographics
NPI:1639223878
Name:HICKS, CLAYTON NATHANIEL (OD)
Entity Type:Individual
Prefix:DR
First Name:CLAYTON
Middle Name:NATHANIEL
Last Name:HICKS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1509 E LIVINGSTON AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43205-2931
Mailing Address - Country:US
Mailing Address - Phone:614-253-5593
Mailing Address - Fax:614-253-6069
Practice Address - Street 1:1489 E LIVINGSTON AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43205-2931
Practice Address - Country:US
Practice Address - Phone:614-253-5593
Practice Address - Fax:614-253-6069
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-23
Last Update Date:2012-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOH 2946152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0142367Medicaid
OH0142367Medicaid