Provider Demographics
NPI:1134285844
Name:KIECKBUSCH, TRAVIS D (MD)
Entity Type:Individual
Prefix:
First Name:TRAVIS
Middle Name:D
Last Name:KIECKBUSCH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:9480 DOUBLE DIAMOND PKWY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89521-5845
Mailing Address - Country:US
Mailing Address - Phone:775-786-1600
Mailing Address - Fax:775-786-7706
Practice Address - Street 1:9480 DOUBLE DIAMOND PKWY
Practice Address - Street 2:SUITE 100
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89521-5845
Practice Address - Country:US
Practice Address - Phone:775-786-1600
Practice Address - Fax:775-786-7706
Is Sole Proprietor?:No
Enumeration Date:2006-12-28
Last Update Date:2018-03-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NV10356207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV002016986Medicaid
11464586OtherCAQH
NVP01420439OtherRR MEDICARE
H78929Medicare UPIN
11464586OtherCAQH