Provider Demographics
NPI:1043352792
Name:NICKELL, JOEL KENTON (OD)
Entity Type:Individual
Prefix:
First Name:JOEL
Middle Name:KENTON
Last Name:NICKELL
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:321 RIVERSIDE DR
Mailing Address - Street 2:
Mailing Address - City:WEST LIBERTY
Mailing Address - State:KY
Mailing Address - Zip Code:41472-1029
Mailing Address - Country:US
Mailing Address - Phone:606-743-2554
Mailing Address - Fax:606-743-2018
Practice Address - Street 1:408 MAIN ST
Practice Address - Street 2:
Practice Address - City:WEST LIBERTY
Practice Address - State:KY
Practice Address - Zip Code:41472-1014
Practice Address - Country:US
Practice Address - Phone:606-743-4111
Practice Address - Fax:606-743-2018
Is Sole Proprietor?:No
Enumeration Date:2007-02-12
Last Update Date:2013-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1035DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY77010353Medicaid
KY3859OtherCHA
KY000000068235OtherBLUECROSSBLUESHIELD
KY77010353Medicaid
KY000000068235OtherBLUECROSSBLUESHIELD