Basic Information
| Provider Information | |||||||||
| NPI: | 1740286558 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HICKEY | ||||||||
| FirstName: | DONALD | ||||||||
| MiddleName: | K | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3355 GLENDALE AVE. | ||||||||
| Address2: | 3RD FLOOR | ||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436142426 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4193835555 | ||||||||
| FaxNumber: | 4193833113 | ||||||||
| Practice Location | |||||||||
| Address1: | 3333 GLENDALE AVE. | ||||||||
| Address2: | |||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 43614 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4193835555 | ||||||||
| FaxNumber: | 4193833113 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2005 | ||||||||
| LastUpdateDate: | 01/11/2018 | ||||||||
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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 | 35045099 | OH | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 141974 | 01 | OH | CARE CHOICES | OTHER | 000000296936 | 01 | OH | ANTHEM-CHS | OTHER | 4203593 | 01 | OH | AETNA | OTHER | 000000030538 | 01 | OH | ANTHEM MEDICAID WWK | OTHER | 002985 | 01 | OH | NATIONWIDE | OTHER | 01-04066 | 01 | OH | UNITED | OTHER | 7244 | 01 | MI | HPM | OTHER | 9564035002 | 01 | OH | CIGNA | OTHER | 000000030538 | 01 | OH | ANTHEM-WWK- | OTHER | 000000200605 | 01 | OH | ANTHEM MEDICAID CHS | OTHER | H587370 | 01 | OH | UTP MEDICARE PIN | OTHER | 0540392 | 05 | OH | MEDICAID | 344428256079 | 01 | OH | CARESOURCES | OTHER |