Provider Demographics
NPI:1679887756
Name:HICKS, BRANDON CLARK (OD)
Entity type:Individual
Prefix:MR
First Name:BRANDON
Middle Name:CLARK
Last Name:HICKS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:999 N CURTIS SUITE 205
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83706-1336
Mailing Address - Country:US
Mailing Address - Phone:208-373-1200
Mailing Address - Fax:208-373-1216
Practice Address - Street 1:999 N CURTIS SUITE 205
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-1336
Practice Address - Country:US
Practice Address - Phone:208-373-1200
Practice Address - Fax:208-373-1216
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-02
Last Update Date:2023-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7719282-9934152W00000X
IDODP-100580152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist