Provider Demographics
NPI:1942731575
Name:HICKMAN, JUSTIN (MD)
Entity Type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:
Last Name:HICKMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:1215 LEE ST
Mailing Address - Street 2:BOX 800710
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22908-0816
Mailing Address - Country:US
Mailing Address - Phone:434-982-0629
Mailing Address - Fax:434-982-0019
Practice Address - Street 1:5115 BERNARD DR STE 201
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24018-4367
Practice Address - Country:US
Practice Address - Phone:540-345-0289
Practice Address - Fax:540-345-9569
Is Sole Proprietor?:No
Enumeration Date:2017-03-24
Last Update Date:2021-06-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA0101272390207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1942731575Medicaid
VA1942731575Medicaid