Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207XX0004X | Foot and Ankle Orthopaedic Surgeon | 2004009696 | MO |
NPI | 1104807924 |
---|---|
Provider Name | Dr. David C Hicks |
First Address | Springfield, MO 65807-7310 |
Second Address | Springfield, MO 65807-7310 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 09/11/2005 |
Last Update Date | 31/08/2012 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
2004009696 | STATE LICENSE (01) | MO |
209273309 | (05) | MO |
H84464 | (02) |