Provider Demographics
NPI:1801905302
Name:HICKS, LARRY W (OD)
Entity type:Individual
Prefix:
First Name:LARRY
Middle Name:W
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 1:900 N SUMNER AVE
Mailing Address - Street 2:
Mailing Address - City:CRESTON
Mailing Address - State:IA
Mailing Address - Zip Code:50801-1351
Mailing Address - Country:US
Mailing Address - Phone:641-782-5970
Mailing Address - Fax:641-782-2756
Practice Address - Street 1:900 N SUMNER AVE
Practice Address - Street 2:
Practice Address - City:CRESTON
Practice Address - State:IA
Practice Address - Zip Code:50801-1351
Practice Address - Country:US
Practice Address - Phone:641-782-5970
Practice Address - Fax:641-782-2756
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-29
Last Update Date:2010-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA01473152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0050625Medicaid
IAT00452Medicare UPIN
IA0050625Medicaid
IA0361520001Medicare NSC