Provider Demographics
NPI:1053388785
Name:NICKELL, KEVIN G (MD)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:G
Last Name:NICKELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1400
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77251-1400
Mailing Address - Country:US
Mailing Address - Phone:713-351-0644
Mailing Address - Fax:713-351-0633
Practice Address - Street 1:7777 SOUTHWEST FWY
Practice Address - Street 2:# 1032
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77074-1802
Practice Address - Country:US
Practice Address - Phone:713-351-0644
Practice Address - Fax:713-351-0633
Is Sole Proprietor?:No
Enumeration Date:2006-03-01
Last Update Date:2007-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ0783208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX039081701Medicaid
TX8G8577Medicare PIN
G22330Medicare UPIN