Provider Demographics
NPI:1750542601
Name:MARK S HICKMAN MD PA
Entity type:Organization
Organization Name:MARK S HICKMAN MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:S
Authorized Official - Last Name:HICKMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:830-625-6259
Mailing Address - Street 1:598 N UNION AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:NEW BRAUNFELS
Mailing Address - State:TX
Mailing Address - Zip Code:78130-4179
Mailing Address - Country:US
Mailing Address - Phone:830-625-6259
Mailing Address - Fax:830-625-6607
Practice Address - Street 1:598 N UNION AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:NEW BRAUNFELS
Practice Address - State:TX
Practice Address - Zip Code:78130-4179
Practice Address - Country:US
Practice Address - Phone:830-625-6259
Practice Address - Fax:830-625-6607
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-24
Last Update Date:2010-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG3461208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00D03KOtherBCBS
TX020009056OtherMEDICARE RAILROAD
TX120477801Medicaid
TX=========7813000000OtherTRICARE
TX120477801Medicaid