Basic Information
Provider Information | |||||||||
NPI: | 1487851168 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | STREET | ||||||||
FirstName: | MEGAN | ||||||||
MiddleName: | HICKMAN | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | HICKMAN | ||||||||
OtherFirstName: | MEGAN | ||||||||
OtherMiddleName: | ANNETTE | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 845347 | ||||||||
Address2: |   | ||||||||
City: | DALLAS | ||||||||
State: | TX | ||||||||
PostalCode: | 752845347 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2144560771 | ||||||||
FaxNumber: | 2144568132 | ||||||||
Practice Location | |||||||||
Address1: | 5323 HARRY HINES BLVD | ||||||||
Address2: |   | ||||||||
City: | DALLAS | ||||||||
State: | TX | ||||||||
PostalCode: | 753907201 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2144560771 | ||||||||
FaxNumber: | 2144568132 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/27/2007 | ||||||||
LastUpdateDate: | 05/23/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | 2007015916 | MO | N |   | Student, Health Care | Student in an Organized Health Care Education/Training Program |   | 2080P0204X | 2010017750 | MO | N |   | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Emergency Medicine | 2080P0204X | P5738 | TX | Y |   | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Emergency Medicine |
No ID Information.