Provider Demographics
NPI:1821139924
Name:HICKMAN, PRENTICE CHARLES (DO)
Entity Type:Individual
Prefix:DR
First Name:PRENTICE
Middle Name:CHARLES
Last Name:HICKMAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 8275
Mailing Address - Street 2:
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79114
Mailing Address - Country:US
Mailing Address - Phone:806-355-8221
Mailing Address - Fax:
Practice Address - Street 1:4139 W. 34TH AVE.
Practice Address - Street 2:
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79109
Practice Address - Country:US
Practice Address - Phone:806-355-8221
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXD6775208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice