Provider Demographics
NPI:1821060419
Name:HICKS, KEVIN W (OD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:W
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 1:131 EUREKA TOWNE CENTER DR
Mailing Address - Street 2:
Mailing Address - City:EUREKA
Mailing Address - State:MO
Mailing Address - Zip Code:63025-1031
Mailing Address - Country:US
Mailing Address - Phone:636-587-9775
Mailing Address - Fax:636-587-9796
Practice Address - Street 1:131 EUREKA TOWNE CENTER DR
Practice Address - Street 2:
Practice Address - City:EUREKA
Practice Address - State:MO
Practice Address - Zip Code:63025-1031
Practice Address - Country:US
Practice Address - Phone:636-587-9775
Practice Address - Fax:636-587-9796
Is Sole Proprietor?:No
Enumeration Date:2006-02-07
Last Update Date:2008-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOT02874152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOU31592Medicare UPIN
MO000025827Medicare ID - Type Unspecified