Provider Demographics
NPI:1487625505
Name:NICOLL, DANIEL LEE (DO)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:LEE
Last Name:NICOLL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:5300 N INDEPENDENCE AVE
Mailing Address - Street 2:SUITE 280
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73112-5556
Mailing Address - Country:US
Mailing Address - Phone:918-786-7878
Mailing Address - Fax:918-786-7884
Practice Address - Street 1:601 E 13TH ST
Practice Address - Street 2:SUITE C
Practice Address - City:GROVE
Practice Address - State:OK
Practice Address - Zip Code:74344-2989
Practice Address - Country:US
Practice Address - Phone:918-786-7878
Practice Address - Fax:918-786-7884
Is Sole Proprietor?:No
Enumeration Date:2006-01-27
Last Update Date:2017-04-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OK3684207Q00000X, 207VX0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100185810CMedicaid
OK800522535OtherMEDICARE GROUP PIN
OK248719105Medicare PIN
G68626Medicare UPIN