Provider Demographics
NPI:1538200498
Name:HICKS, GREGORY WILLARD (OD)
Entity type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:WILLARD
Last Name:HICKS
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 1:2331 COLUMBUS AVE
Mailing Address - Street 2:
Mailing Address - City:SANDUSKY
Mailing Address - State:OH
Mailing Address - Zip Code:44870-4827
Mailing Address - Country:US
Mailing Address - Phone:419-626-0272
Mailing Address - Fax:419-626-1546
Practice Address - Street 1:2331 COLUMBUS AVE
Practice Address - Street 2:
Practice Address - City:SANDUSKY
Practice Address - State:OH
Practice Address - Zip Code:44870-4827
Practice Address - Country:US
Practice Address - Phone:419-626-0272
Practice Address - Fax:419-626-1546
Is Sole Proprietor?:No
Enumeration Date:2007-02-12
Last Update Date:2007-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3742T188152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0575855Medicaid
OH0575855Medicaid
OHHI0676621Medicare PIN