Provider Demographics
NPI:1760456958
Name:HICKMAN, WILLET J (MD)
Entity Type:Individual
Prefix:
First Name:WILLET
Middle Name:J
Last Name:HICKMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5500
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75712-5500
Mailing Address - Country:US
Mailing Address - Phone:903-324-6450
Mailing Address - Fax:903-593-7852
Practice Address - Street 1:520 DOUGLAS BLVD
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75702-8307
Practice Address - Country:US
Practice Address - Phone:903-593-1721
Practice Address - Fax:903-510-8724
Is Sole Proprietor?:No
Enumeration Date:2006-02-14
Last Update Date:2012-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE3707207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX128079404Medicaid
TX128079404Medicaid
B23480Medicare UPIN
TX83Y752Medicare ID - Type Unspecified