Provider Demographics
NPI:1114915030
Name:NACOL, MICHAEL EDWIN SAMUEL (MD)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:EDWIN SAMUEL
Last Name:NACOL
Suffix:
Gender:M
Credentials:MD
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Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:3201 S AUSTIN AVE
Mailing Address - Street 2:130
Mailing Address - City:GEORGETOWN
Mailing Address - State:TX
Mailing Address - Zip Code:78626-7537
Mailing Address - Country:US
Mailing Address - Phone:512-863-7440
Mailing Address - Fax:512-869-8716
Practice Address - Street 1:3201 S AUSTIN AVE
Practice Address - Street 2:130
Practice Address - City:GEORGETOWN
Practice Address - State:TX
Practice Address - Zip Code:78626-7537
Practice Address - Country:US
Practice Address - Phone:512-863-7440
Practice Address - Fax:512-869-8716
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-13
Last Update Date:2010-01-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXF6987207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX114924702Medicaid
TX114924702Medicaid
TX00GX23Medicare ID - Type Unspecified