Provider Demographics
NPI:1770553257
Name:HICKLIN, D MARK (M D)
Entity type:Individual
Prefix:
First Name:D
Middle Name:MARK
Last Name:HICKLIN
Suffix:
Gender:M
Credentials:M D
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 2168
Mailing Address - Street 2:
Mailing Address - City:SPARTANBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29304-2168
Mailing Address - Country:US
Mailing Address - Phone:864-560-4304
Mailing Address - Fax:864-560-4413
Practice Address - Street 1:120 HEYWOOD AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29302-1210
Practice Address - Country:US
Practice Address - Phone:864-573-9595
Practice Address - Fax:864-585-3752
Is Sole Proprietor?:No
Enumeration Date:2006-01-25
Last Update Date:2007-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC11179207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC111792Medicaid
SC4584043OtherAETNA
SC58864OtherMEDCOST
NC7906539Medicaid
SCB91944Medicare PIN
SCB91944Medicare UPIN