1548211634 NPI number — DR. DOMINIQUE A NICKSON MD

Table of content: DR. DOMINIQUE A NICKSON MD (NPI 1548211634)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548211634 NPI number — DR. DOMINIQUE A NICKSON MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NICKSON
Provider First Name:
DOMINIQUE
Provider Middle Name:
A
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1548211634
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/07/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8876 SYNERGY DR STE 100
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MCKINNEY
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75070-1276
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
972-547-0047
Provider Business Mailing Address Fax Number:
877-400-6329

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8876 SYNERGY DR
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
MCKINNEY
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75070-1276
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
972-547-0047
Provider Business Practice Location Address Fax Number:
877-400-6329
Provider Enumeration Date:
05/13/2006

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: 207XX0004X , with the licence number:  L8866 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207X00000X , with the licence number: L8866 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 6512550001 . This is a "DME PTAN" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: P01047820 . This is a "RAILROAD MEDICARE PTAN" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: TXB128126 . This is a "MEDICARE PTAN" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: L8866 . This is a "LICENSE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 2454999 . This is a "UNITED HEALTHCARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: P00658084 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 285510801 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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