Provider Demographics
NPI:1396843942
Name:BRYAN HICKS MD PA
Entity type:Organization
Organization Name:BRYAN HICKS MD PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:CRAIG
Authorized Official - Last Name:HICKS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:352-368-5858
Mailing Address - Street 1:5349 SW COLLEGE RD
Mailing Address - Street 2:STE 2
Mailing Address - City:OCALA
Mailing Address - State:FL
Mailing Address - Zip Code:34474-5717
Mailing Address - Country:US
Mailing Address - Phone:352-368-5858
Mailing Address - Fax:352-368-2044
Practice Address - Street 1:5349 SW COLLEGE RD
Practice Address - Street 2:STE 2
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34474-5717
Practice Address - Country:US
Practice Address - Phone:352-368-5858
Practice Address - Fax:352-368-2044
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2008-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME47583207ND0101X, 207ND0900X, 207NI0002X, 207NS0135X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Single Specialty
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathologyGroup - Single Specialty
No207NI0002XAllopathic & Osteopathic PhysiciansDermatologyClinical & Laboratory Dermatological ImmunologyGroup - Single Specialty
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Single Specialty