Healthcare Provider Details

I. General information

NPI: 1750681391
Provider Name (Legal Business Name): KEVIN MICHAEL FICKENSCHER SR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/29/2010
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3499 NW BRAID DRIVE
BEND OR
97701-8682
US

IV. Provider business mailing address

7710 WOODMONT AVENUE SUITE 211
BETHESDA MD
20814
US

V. Phone/Fax

Practice location:
  • Phone: 415-307-7358
  • Fax: 415-223-9383
Mailing address:
  • Phone: 415-450-1515
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberG84904
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: