Provider Demographics
NPI:1649283227
Name:HICKS, RONALD J (MD)
Entity type:Individual
Prefix:
First Name:RONALD
Middle Name:J
Last Name:HICKS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1720 E. VENICE AVENUE - 2ND FLOOR
Mailing Address - Street 2:
Mailing Address - City:VENICE
Mailing Address - State:FL
Mailing Address - Zip Code:34292-3190
Mailing Address - Country:US
Mailing Address - Phone:941-483-9730
Mailing Address - Fax:941-483-9745
Practice Address - Street 1:1720 E. VENICE AVENUE - 2ND FLOOR
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:FL
Practice Address - Zip Code:34292-3190
Practice Address - Country:US
Practice Address - Phone:941-483-9730
Practice Address - Fax:941-483-9745
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2010-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME43961207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL79841OtherBCBS
FL068658100Medicaid
FL068658100Medicaid
FL79841AMedicare UPIN