Provider Demographics
NPI:1225604036
Name:HICKS, ZACHARY (DO)
Entity type:Individual
Prefix:
First Name:ZACHARY
Middle Name:
Last Name:HICKS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:374TH MEDICAL GROUP
Mailing Address - Street 2:UNIT 5071
Mailing Address - City:APO
Mailing Address - State:AP
Mailing Address - Zip Code:96328-5071
Mailing Address - Country:US
Mailing Address - Phone:315-225-7740
Mailing Address - Fax:
Practice Address - Street 1:374TH MEDICAL GROUP
Practice Address - Street 2:UNIT 5071
Practice Address - City:APO
Practice Address - State:AP
Practice Address - Zip Code:96328-5071
Practice Address - Country:US
Practice Address - Phone:315-225-7740
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-02
Last Update Date:2024-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02007276A207Q00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty