Healthcare Provider Details

I. General information

NPI: 1356347603
Provider Name (Legal Business Name): DAVID R FICKLEN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2005
Last Update Date: 05/18/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 MEDICAL PARK LN STE A
HUNTSVILLE TX
77340-4975
US

IV. Provider business mailing address

102 MEDICAL PARK LN STE A
HUNTSVILLE TX
77340-4975
US

V. Phone/Fax

Practice location:
  • Phone: 936-435-0014
  • Fax: 936-435-9108
Mailing address:
  • Phone: 936-435-0014
  • Fax: 936-435-9108

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberK5929
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: