Provider Demographics
NPI:1104807924
Name:HICKS, DAVID C (MD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:C
Last Name:HICKS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:3555 S NATIONAL AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65807-7310
Mailing Address - Country:US
Mailing Address - Phone:417-875-3800
Mailing Address - Fax:417-875-3176
Practice Address - Street 1:3555 S NATIONAL AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-7310
Practice Address - Country:US
Practice Address - Phone:417-875-3800
Practice Address - Fax:417-875-3176
Is Sole Proprietor?:No
Enumeration Date:2005-11-09
Last Update Date:2012-08-31
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO2004009696207XX0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0004XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryFoot and Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO209273309Medicaid
MO2004009696OtherSTATE LICENSE
MO209273309Medicaid
H84464Medicare UPIN