Healthcare Provider Details

I. General information

NPI: 1487625505
Provider Name (Legal Business Name): DANIEL LEE NICOLL DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/27/2006
Last Update Date: 04/05/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 E 13TH ST SUITE C
GROVE OK
74344-2989
US

IV. Provider business mailing address

5300 N INDEPENDENCE AVE SUITE 280
OKLAHOMA CITY OK
73112-5556
US

V. Phone/Fax

Practice location:
  • Phone: 918-786-7878
  • Fax: 918-786-7884
Mailing address:
  • Phone: 918-786-7878
  • Fax: 918-786-7884

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number3684
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code207VX0000X
TaxonomyObstetrics Physician
License Number3684
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: