Provider Demographics
NPI:1942204284
Name:HICKS, JOHN B (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:B
Last Name:HICKS
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 1:1213 56TH ST
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39305-1447
Mailing Address - Country:US
Mailing Address - Phone:601-483-7812
Mailing Address - Fax:601-482-4269
Practice Address - Street 1:1213 56TH ST
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:MS
Practice Address - Zip Code:39305-1447
Practice Address - Country:US
Practice Address - Phone:601-483-7812
Practice Address - Fax:601-482-4269
Is Sole Proprietor?:No
Enumeration Date:2005-06-01
Last Update Date:2008-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS09618207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00123663Medicaid
MSC48287Medicare UPIN
MS00123663Medicaid
MS060000869Medicare PIN
MS1110400001Medicare NSC