MEDICARE: DR. KIM NICKELSON MD

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	MA50822	FL

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

General Provider Information

NPI Number	:	1861473589
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KIM NICKELSON MD

Provider Business Mailing Address
First Line	:	6101 BLUE LAGOON DR STE 200
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33126-3168
Country	:	US
Telephone Number	:	305-500-2000
Fax Number	:

Provider Business Practice Location Address
First Line	:	301 NW 84TH AVE STE 101
Second Line	:
City	:	PLANTATION
State	:	FL
Zip	:	33324-1807
Country	:	US
Telephone Number	:	954-581-1900
Fax Number	:

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

Provider Enumeration Date	:	11/09/2005
Last Update Date	:	09/23/2022

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Directions to “ DR. KIM NICKELSON MD” Practice Location

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