Provider Demographics
NPI:1205976271
Name:HICKINSON, RICARDO (OD)
Entity type:Individual
Prefix:DR
First Name:RICARDO
Middle Name:
Last Name:HICKINSON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19800 W 8 MILE RD
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48075-5730
Mailing Address - Country:US
Mailing Address - Phone:248-352-6900
Mailing Address - Fax:248-354-0345
Practice Address - Street 1:19800 W 8 MILE RD
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-5730
Practice Address - Country:US
Practice Address - Phone:248-352-6900
Practice Address - Fax:248-354-0345
Is Sole Proprietor?:No
Enumeration Date:2007-02-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901003681152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIU49423Medicare UPIN