Provider Demographics
NPI:1710025721
Name:T JEFFERSON HICKS OD PC
Entity Type:Organization
Organization Name:T JEFFERSON HICKS OD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:J
Authorized Official - Last Name:HICKS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:251-675-2718
Mailing Address - Street 1:PO BOX 687
Mailing Address - Street 2:
Mailing Address - City:SARALAND
Mailing Address - State:AL
Mailing Address - Zip Code:36571-0687
Mailing Address - Country:US
Mailing Address - Phone:251-675-2718
Mailing Address - Fax:
Practice Address - Street 1:1127 HIGHWAY 43 S
Practice Address - Street 2:
Practice Address - City:SARALAND
Practice Address - State:AL
Practice Address - Zip Code:36571-3720
Practice Address - Country:US
Practice Address - Phone:251-675-2718
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-02
Last Update Date:2010-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALS340TA047152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL6229460001Medicare NSC