Provider Demographics
NPI:1821120072
Name:HANCOCK, HEATHER ALICIA (MD)
Entity Type:Individual
Prefix:DR
First Name:HEATHER
Middle Name:ALICIA
Last Name:HANCOCK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 DOVER LN
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:MS
Mailing Address - Zip Code:39110-9418
Mailing Address - Country:US
Mailing Address - Phone:901-491-9952
Mailing Address - Fax:
Practice Address - Street 1:2500 N STATE ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4500
Practice Address - Country:US
Practice Address - Phone:601-984-5020
Practice Address - Fax:601-984-5042
Is Sole Proprietor?:No
Enumeration Date:2007-03-12
Last Update Date:2017-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN43457207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
1821120072OtherNPI
MSP00864517OtherRAILROAD MEDICARE
TN3001559OtherMEDICARE PTAN
TN3001559Medicaid
MS302I189340Medicare PIN
1821120072OtherNPI