Provider Demographics
NPI:1669490413
Name:HICKS, KEVIN O (MD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:O
Last Name:HICKS
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 1:113 NATIONWIDE DR
Mailing Address - Street 2:
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24502-4272
Mailing Address - Country:US
Mailing Address - Phone:434-237-4004
Mailing Address - Fax:434-237-4450
Practice Address - Street 1:113 NATIONWIDE DR
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24502-4272
Practice Address - Country:US
Practice Address - Phone:434-237-4004
Practice Address - Fax:434-237-4450
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2007-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101234478174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA7248199Medicaid
VA7248181Medicaid
001613R25Medicare ID - Type UnspecifiedMEDICARE #
VA7248181Medicaid
P00035656Medicare ID - Type UnspecifiedRAILROAD MEDICARE #
001614C74Medicare ID - Type UnspecifiedMEDICARE #
VA7248199Medicaid