Provider Demographics
NPI:1730283250
Name:HICKS, LAURENCE V (DO)
Entity Type:Individual
Prefix:DR
First Name:LAURENCE
Middle Name:V
Last Name:HICKS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:236 MARTIN ST
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-4542
Mailing Address - Country:US
Mailing Address - Phone:208-733-4444
Mailing Address - Fax:208-733-4456
Practice Address - Street 1:236 MARTIN ST
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-4542
Practice Address - Country:US
Practice Address - Phone:208-733-4444
Practice Address - Fax:208-733-4456
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-13
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDO-180207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID80416400Medicaid
ID1302282Medicare ID - Type Unspecified
IDG10037Medicare UPIN