Basic Information
| Provider Information | |||||||||
| NPI: | 1386617157 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HICKS | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | G. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 601 ELMWOOD AVENUE | ||||||||
| Address2: | URMC BOX 626 | ||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146420001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5852753184 | ||||||||
| FaxNumber: | 5852762802 | ||||||||
| Practice Location | |||||||||
| Address1: | 601 ELMWOOD AVENUE | ||||||||
| Address2: | UNIVERSITY OF ROCHESTER MEDICAL CENTER, BOX 626 | ||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146420001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5852753184 | ||||||||
| FaxNumber: | 5852762802 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/10/2006 | ||||||||
| LastUpdateDate: | 05/03/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0101X | 183009-1 | NY | Y | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology |
ID Information
| ID | Type | State | Issuer | Description | 00026229002 | 01 | NY | UNIVERA INS. # | OTHER |