MEDICARE: DAVID R FICKLEN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	K5929	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	8M5490	OTHER		BCBS

General Provider Information

NPI Number	:	1356347603
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DAVID R FICKLEN

Provider Business Mailing Address
First Line	:	102 MEDICAL PARK LN STE A
Second Line	:
City	:	HUNTSVILLE
State	:	TX
Zip	:	77340-4975
Country	:	US
Telephone Number	:	936-435-0014
Fax Number	:	936-435-9108

Provider Business Practice Location Address
First Line	:	102 MEDICAL PARK LN STE A
Second Line	:
City	:	HUNTSVILLE
State	:	TX
Zip	:	77340-4975
Country	:	US
Telephone Number	:	936-435-0014
Fax Number	:	936-435-9108

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/22/2005
Last Update Date	:	05/18/2011

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Directions to “ DAVID R FICKLEN ” Practice Location

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