Provider Demographics
NPI:1881816411
Name:HICKERSON, ADAM D (MD)
Entity Type:Individual
Prefix:
First Name:ADAM
Middle Name:D
Last Name:HICKERSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 W BONITA AVE
Mailing Address - Street 2:100
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91767-1865
Mailing Address - Country:US
Mailing Address - Phone:909-623-3428
Mailing Address - Fax:909-622-1923
Practice Address - Street 1:210 W BONITA AVE
Practice Address - Street 2:100
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91767-1865
Practice Address - Country:US
Practice Address - Phone:909-623-3428
Practice Address - Fax:909-622-1923
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2014-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA107318208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology