Healthcare Provider Details

I. General information

NPI: 1497909683
Provider Name (Legal Business Name): DAVID NICKELS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/14/2008
Last Update Date: 08/27/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 ROSE ST ROOM HX-315E
LEXINGTON KY
40536-0001
US

IV. Provider business mailing address

800 ROSE STREET ROOM HX-315E
LEXINGTON KY
40536-0293
US

V. Phone/Fax

Practice location:
  • Phone: 859-323-5069
  • Fax:
Mailing address:
  • Phone: 859-323-5069
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085B0100X
TaxonomyBody Imaging Physician
License Number43406
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberR1475
License Number StateKY
# 3
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number43406
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: