Provider Demographics
NPI:1063455905
Name:MENDRYGAL, NIKOLAS (MD)
Entity Type:Individual
Prefix:
First Name:NIKOLAS
Middle Name:
Last Name:MENDRYGAL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12221 MERIT DRIVE
Mailing Address - Street 2:STE 1610
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75251
Mailing Address - Country:US
Mailing Address - Phone:214-217-1911
Mailing Address - Fax:214-217-1912
Practice Address - Street 1:7777 FOREST LANE
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75230
Practice Address - Country:US
Practice Address - Phone:972-248-3017
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2014-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM3017207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX184396301Medicaid
TX8V3528OtherBCBS
TX184396302Medicaid
TXP00386322OtherRAILROAD
TX342585YKN5Medicare PIN
I71391Medicare UPIN
TX184396301Medicaid