Provider Demographics
NPI:1134149131
Name:HICKS, CARLTON T (OD)
Entity type:Individual
Prefix:DR
First Name:CARLTON
Middle Name:T
Last Name:HICKS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:312 REDFERN VILLAGE
Mailing Address - Street 2:
Mailing Address - City:ST SIMONS ISLAND
Mailing Address - State:GA
Mailing Address - Zip Code:31522-1631
Mailing Address - Country:US
Mailing Address - Phone:912-638-8652
Mailing Address - Fax:912-638-0490
Practice Address - Street 1:312 REDFERN VILLAGE
Practice Address - Street 2:
Practice Address - City:ST SIMONS ISLAND
Practice Address - State:GA
Practice Address - Zip Code:31522-1631
Practice Address - Country:US
Practice Address - Phone:912-638-8652
Practice Address - Fax:912-638-0490
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-20
Last Update Date:2011-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT000651152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000068307AMedicaid
GAGRP3399Medicare ID - Type Unspecified
GA000068307AMedicaid
GA1268460001Medicare NSC