Provider Demographics
NPI:1699203091
Name:HICKSON, MARY ALICE SALLMAN (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ALICE SALLMAN
Last Name:HICKSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:ALICE
Other - Last Name:SALLMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:11511 SHADOW CREEK PKWY
Mailing Address - Street 2:
Mailing Address - City:PEARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:77584-7298
Mailing Address - Country:US
Mailing Address - Phone:713-442-4997
Mailing Address - Fax:
Practice Address - Street 1:560 MEYERLAND PLAZA MALL
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77096-1615
Practice Address - Country:US
Practice Address - Phone:713-442-3222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-30
Last Update Date:2021-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXT1099207N00000X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX427148801Medicaid
TX427148802Medicaid
TX427148803Medicaid