Basic Information
| Provider Information | |||||||||
| NPI: | 1649283227 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HICKS | ||||||||
| FirstName: | RONALD | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1720 E. VENICE AVENUE - 2ND FLOOR | ||||||||
| Address2: | |||||||||
| City: | VENICE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 342923190 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9414839730 | ||||||||
| FaxNumber: | 9414839745 | ||||||||
| Practice Location | |||||||||
| Address1: | 1720 E. VENICE AVENUE - 2ND FLOOR | ||||||||
| Address2: | |||||||||
| City: | VENICE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 342923190 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9414839730 | ||||||||
| FaxNumber: | 9414839745 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/14/2006 | ||||||||
| LastUpdateDate: | 08/24/2010 | ||||||||
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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 | 207Q00000X | ME43961 | FL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 79841 | 01 | FL | BCBS | OTHER | 068658100 | 05 | FL | MEDICAID |