Provider Demographics
NPI:1205801859
Name:AUTRY, CASANDRA HICKS (MD)
Entity type:Individual
Prefix:DR
First Name:CASANDRA
Middle Name:HICKS
Last Name:AUTRY
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 1:41 HIGHWAY 34 S
Mailing Address - Street 2:
Mailing Address - City:COLTS NECK
Mailing Address - State:NJ
Mailing Address - Zip Code:07722-1753
Mailing Address - Country:US
Mailing Address - Phone:732-308-2255
Mailing Address - Fax:732-308-0081
Practice Address - Street 1:41 HIGHWAY 34 S
Practice Address - Street 2:
Practice Address - City:COLTS NECK
Practice Address - State:NJ
Practice Address - Zip Code:07722-1753
Practice Address - Country:US
Practice Address - Phone:732-308-2255
Practice Address - Fax:732-308-0081
Is Sole Proprietor?:No
Enumeration Date:2006-02-17
Last Update Date:2012-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA06928800207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8097607Medicaid
NJ8097607Medicaid
NJG95329Medicare UPIN