Provider Demographics
NPI:1790903144
Name:HICKS, SCOTTY LLOYD (OD)
Entity Type:Individual
Prefix:DR
First Name:SCOTTY
Middle Name:LLOYD
Last Name:HICKS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1208 N 18TH ST
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71201-5430
Mailing Address - Country:US
Mailing Address - Phone:318-322-2020
Mailing Address - Fax:318-387-4242
Practice Address - Street 1:1208 N 18TH ST
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71201-5430
Practice Address - Country:US
Practice Address - Phone:318-322-2020
Practice Address - Fax:318-387-4242
Is Sole Proprietor?:No
Enumeration Date:2007-04-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1183-341T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1126551Medicaid
LA4B2607070Medicare ID - Type Unspecified
LA1126551Medicaid