1407812282 NPI number — DONALD DOUGLAS HICKEY MEDICAL DOCTOR

Table of content: DONALD DOUGLAS HICKEY MEDICAL DOCTOR (NPI 1407812282)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407812282 NPI number — DONALD DOUGLAS HICKEY MEDICAL DOCTOR

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HICKEY
Provider First Name:
DONALD
Provider Middle Name:
DOUGLAS
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MEDICAL DOCTOR
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1407812282
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
POST OFFICE BOX 803
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
AMHERST
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
14226-0803
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
716-839-5474
Provider Business Mailing Address Fax Number:
716-839-4090

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4476 MAIN STREET
Provider Second Line Business Practice Location Address:
STE 104
Provider Business Practice Location Address City Name:
AMHERST
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
14226
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
716-839-5474
Provider Business Practice Location Address Fax Number:
716-839-4090
Provider Enumeration Date:
04/21/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208600000X , with the licence number:  138795 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 01136685 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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