Provider Demographics
NPI:1457382335
Name:TOMMY L. HICKS, M.D., INC.
Entity Type:Organization
Organization Name:TOMMY L. HICKS, M.D., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:TOMMY
Authorized Official - Middle Name:LEONARD
Authorized Official - Last Name:HICKS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:949-588-7262
Mailing Address - Street 1:23521 PASEO DE VALENCIA STE 108
Mailing Address - Street 2:
Mailing Address - City:LAGUNA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:92653-3137
Mailing Address - Country:US
Mailing Address - Phone:949-588-7262
Mailing Address - Fax:949-588-7260
Practice Address - Street 1:23521 PASEO DE VALENCIA STE 108
Practice Address - Street 2:
Practice Address - City:LAGUNA HILLS
Practice Address - State:CA
Practice Address - Zip Code:92653-3137
Practice Address - Country:US
Practice Address - Phone:949-588-7262
Practice Address - Fax:949-588-7260
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-06
Last Update Date:2007-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG48888207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G488880Medicaid
CAW19612Medicare PIN