Provider Demographics
NPI:1740292713
Name:HICKS, THOMAS JEFFERSON (OD)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:JEFFERSON
Last Name:HICKS
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:PO BOX 687
Mailing Address - Street 2:
Mailing Address - City:SARALAND
Mailing Address - State:AL
Mailing Address - Zip Code:36571-0687
Mailing Address - Country:US
Mailing Address - Phone:251-675-2718
Mailing Address - Fax:251-675-9827
Practice Address - Street 1:1127 HIGHWAY 43 SOUTH
Practice Address - Street 2:
Practice Address - City:SARALAND
Practice Address - State:AL
Practice Address - Zip Code:36571-3720
Practice Address - Country:US
Practice Address - Phone:251-675-2718
Practice Address - Fax:251-675-9827
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-11
Last Update Date:2010-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALS340TA047152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
T68936Medicare UPIN
AL0611150001Medicare NSC