Provider Demographics
NPI:1861576142
Name:HICKEY, MICHAEL THOMAS (DPM)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:THOMAS
Last Name:HICKEY
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:53 SUNDANCE DR
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91766-4874
Mailing Address - Country:US
Mailing Address - Phone:760-951-2000
Mailing Address - Fax:
Practice Address - Street 1:14400 BEAR VALLEY RD
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92392-5470
Practice Address - Country:US
Practice Address - Phone:760-951-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2013-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE2317213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP00385025OtherRR MEDICARE
CAGRE001960Medicaid
CA000E23171Medicare PIN
CAT11282Medicare UPIN
CAP00385025OtherRR MEDICARE