Provider Demographics
NPI:1740253202
Name:HICKMAN, TIMOTHY SCOTT (OD)
Entity type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:SCOTT
Last Name:HICKMAN
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 1:114 CENTRAL AVE NW
Mailing Address - Street 2:
Mailing Address - City:ORANGE CITY
Mailing Address - State:IA
Mailing Address - Zip Code:51041-1433
Mailing Address - Country:US
Mailing Address - Phone:712-737-4246
Mailing Address - Fax:712-707-9855
Practice Address - Street 1:114 CENTRAL AVE NW
Practice Address - Street 2:
Practice Address - City:ORANGE CITY
Practice Address - State:IA
Practice Address - Zip Code:51041-1458
Practice Address - Country:US
Practice Address - Phone:712-737-4246
Practice Address - Fax:712-707-9855
Is Sole Proprietor?:No
Enumeration Date:2006-02-07
Last Update Date:2008-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA01833152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1231662Medicaid
IA1231662Medicaid
IAP00054681Medicare PIN