Provider Demographics
NPI:1548284383
Name:HICKLIN, THOMAS A I (MD)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:A
Last Name:HICKLIN
Suffix:I
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1520 SAN PABLO STREET
Mailing Address - Street 2:SUITE 1652
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90033-5321
Mailing Address - Country:US
Mailing Address - Phone:323-442-6000
Mailing Address - Fax:323-442-6001
Practice Address - Street 1:1520 SAN PABLO STREET
Practice Address - Street 2:SUITE 1652
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90033-5321
Practice Address - Country:US
Practice Address - Phone:323-442-6000
Practice Address - Fax:323-442-6001
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2012-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC325062084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00C325060OtherBLUE SHIELD
CA0633629OtherCHAMPUS
CAC32506AMedicare ID - Type Unspecified