Provider Demographics
NPI:1972661254
Name:HICKS, KIMBERLY (MD)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:HICKS
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 1:3317 ELM ST
Mailing Address - Street 2:SUITE 102
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94609-3052
Mailing Address - Country:US
Mailing Address - Phone:510-595-9880
Mailing Address - Fax:510-595-9881
Practice Address - Street 1:3317 ELM ST
Practice Address - Street 2:SUITE 102
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94609-3052
Practice Address - Country:US
Practice Address - Phone:510-595-9880
Practice Address - Fax:510-595-9881
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-05
Last Update Date:2007-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG79714207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAF90733Medicare UPIN
CA00G797140Medicare ID - Type Unspecified