Provider Demographics
NPI:1679700959
Name:HICKERSON, LINDSAY (MD)
Entity Type:Individual
Prefix:
First Name:LINDSAY
Middle Name:
Last Name:HICKERSON
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 1:3300 S FISKE BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-4306
Mailing Address - Country:US
Mailing Address - Phone:321-434-1981
Mailing Address - Fax:321-951-7408
Practice Address - Street 1:1350 HICKORY ST
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901
Practice Address - Country:US
Practice Address - Phone:321-434-1401
Practice Address - Fax:321-434-1667
Is Sole Proprietor?:No
Enumeration Date:2009-06-15
Last Update Date:2019-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK31400207XX0801X
NY273286207XX0801X
FLME140535207XX0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0801XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Trauma
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLLD519OtherMEDICARE
FL102741400Medicaid
FLLD522OtherMEDICARE