Provider Demographics
NPI:1821086752
Name:HICKS, BRYAN C (MD)
Entity Type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:C
Last Name:HICKS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5349 SW COLLEGE RD
Mailing Address - Street 2:SUITE 2
Mailing Address - City:OCALA
Mailing Address - State:FL
Mailing Address - Zip Code:34474-5717
Mailing Address - Country:US
Mailing Address - Phone:352-368-5858
Mailing Address - Fax:352-368-2044
Practice Address - Street 1:5349 SW COLLEGE RD
Practice Address - Street 2:SUITE 2
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34474-5717
Practice Address - Country:US
Practice Address - Phone:352-368-5858
Practice Address - Fax:352-368-2044
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-13
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME47583207ND0101X, 207N00000X, 207NS0135X, 207ND0900X
FLME47586207NI0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
Not Answered207N00000XAllopathic & Osteopathic PhysiciansDermatology
Not Answered207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Not Answered207NI0002XAllopathic & Osteopathic PhysiciansDermatologyClinical & Laboratory Dermatological Immunology
Not Answered207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLD58298Medicare UPIN
FL73256Medicare ID - Type UnspecifiedDERMATOLOGY