Provider Demographics
NPI:1679575922
Name:HICKS, THOMAS H (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:H
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 1:6325 E TANQUE VERDE RD
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85715-3808
Mailing Address - Country:US
Mailing Address - Phone:520-546-7137
Mailing Address - Fax:520-885-7396
Practice Address - Street 1:6325 E TANQUE VERDE RD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85715-3808
Practice Address - Country:US
Practice Address - Phone:520-546-7137
Practice Address - Fax:520-885-7396
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-01
Last Update Date:2014-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ7244174400000X, 208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ221276Medicaid
0288760001Medicare NSC
D37020Medicare PIN