Provider Demographics
NPI:1982704789
Name:HICKS, KEVIN BERNARD (DO)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:BERNARD
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 1:6105 PEACHTREE DUNWOODY RD STE C115
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30328-5943
Mailing Address - Country:US
Mailing Address - Phone:770-481-0019
Mailing Address - Fax:770-481-0408
Practice Address - Street 1:6105 PEACHTREE DUNWOODY RD STE C115
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30328-5943
Practice Address - Country:US
Practice Address - Phone:770-481-0019
Practice Address - Fax:770-481-0408
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-22
Last Update Date:2019-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA52959207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA08BBRFCMedicare ID - Type UnspecifiedMEDICARE IP NUMBER
GAH94663Medicare UPIN