Provider Demographics
NPI:1700821584
Name:HICKOK, BRIAN J (MD)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:J
Last Name:HICKOK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:980 W. IRONWOOD DRIVE
Mailing Address - Street 2:SUITE 302
Mailing Address - City:COEUR D'ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-9998
Mailing Address - Country:US
Mailing Address - Phone:208-292-5437
Mailing Address - Fax:208-292-5441
Practice Address - Street 1:980 W IRONWOOD DR
Practice Address - Street 2:STE 302
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814
Practice Address - Country:US
Practice Address - Phone:208-292-5437
Practice Address - Fax:208-292-5437
Is Sole Proprietor?:No
Enumeration Date:2006-06-17
Last Update Date:2012-09-05
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IDM9558208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
H84342Medicare UPIN