Basic Information
| Provider Information | |||||||||
| NPI: | 1619337532 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HICKS | ||||||||
| FirstName: | ILZE | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 551178 | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322551178 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8049124947 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4348 SOUTHPOINT BLVD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322160986 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042811915 | ||||||||
| FaxNumber: | 9042811119 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/04/2016 | ||||||||
| LastUpdateDate: | 10/17/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | ME124762 | FL | Y | Allopathic & Osteopathic Physicians | General Practice |
No ID Information.