Provider Demographics
NPI:1720186802
Name:HICKS, CHARLES E
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:E
Last Name:HICKS
Suffix:
Gender:M
Credentials:
Other - Prefix:DR
Other - First Name:CHARLES
Other - Middle Name:E
Other - Last Name:HICKS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DPM
Mailing Address - Street 1:PO BOX 907
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:MS
Mailing Address - Zip Code:38732-0907
Mailing Address - Country:US
Mailing Address - Phone:662-843-3668
Mailing Address - Fax:662-846-1984
Practice Address - Street 1:140 NORTH ST
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:MS
Practice Address - Zip Code:38732-2744
Practice Address - Country:US
Practice Address - Phone:662-843-3668
Practice Address - Fax:662-846-1894
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS80066213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00013450Medicaid
T20871Medicare UPIN
MS00013450Medicaid