Provider Demographics
NPI:1588863450
Name:HICKS, CORY JOSEPH (MD)
Entity type:Individual
Prefix:
First Name:CORY
Middle Name:JOSEPH
Last Name:HICKS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4273 MONTGOMERY BLVD NE
Mailing Address - Street 2:SUITE 200 E
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-6748
Mailing Address - Country:US
Mailing Address - Phone:505-821-5992
Mailing Address - Fax:505-821-6692
Practice Address - Street 1:4901 LANG AVE NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-4495
Practice Address - Country:US
Practice Address - Phone:505-842-8171
Practice Address - Fax:505-246-0684
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-12
Last Update Date:2020-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXBP10027616207R00000X
TXN7105207R00000X, 207RC0200X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM55236251Medicaid
TXN7105OtherMEDICAL LICENSE
NMMD2014-0172OtherMEDICAL LICENSE