Provider Demographics
NPI:1225078660
Name:MCNICHOLS, TIMOTHY KENT (MD)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:KENT
Last Name:MCNICHOLS
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:PO BOX 36210
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85740-6210
Mailing Address - Country:US
Mailing Address - Phone:520-219-2474
Mailing Address - Fax:520-531-0128
Practice Address - Street 1:6130 NORTH LACHOLLA BLVD #117
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85741
Practice Address - Country:US
Practice Address - Phone:520-219-2474
Practice Address - Fax:520-531-0128
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-07
Last Update Date:2008-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2000157963207R00000X
AZ40509207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
126895OtherBLUE CROSS/BLUE SHIELD
MO205007701Medicaid
126895OtherBLUE CROSS/BLUE SHIELD
MO205007701Medicaid
117012734Medicare PIN