Provider Demographics
NPI:1073628228
Name:HICKS, HOWARD RANDALL (MD)
Entity type:Individual
Prefix:MR
First Name:HOWARD
Middle Name:RANDALL
Last Name:HICKS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:4060 4TH AVE
Mailing Address - Street 2:#615
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103
Mailing Address - Country:US
Mailing Address - Phone:619-298-7135
Mailing Address - Fax:619-298-2461
Practice Address - Street 1:4060 4TH AVE
Practice Address - Street 2:#615
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103
Practice Address - Country:US
Practice Address - Phone:619-298-7135
Practice Address - Fax:619-298-2461
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2010-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG0474392084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
A92724Medicare UPIN
CAG47439Medicare ID - Type Unspecified