Provider Demographics
NPI:1548211634
Name:NICKSON, DOMINIQUE A (MD)
Entity Type:Individual
Prefix:DR
First Name:DOMINIQUE
Middle Name:A
Last Name:NICKSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:8865 SYNERGY DR STE 101
Mailing Address - Street 2:
Mailing Address - City:MCKINNEY
Mailing Address - State:TX
Mailing Address - Zip Code:75070-6522
Mailing Address - Country:US
Mailing Address - Phone:972-547-0047
Mailing Address - Fax:972-547-0065
Practice Address - Street 1:8865 SYNERGY DR
Practice Address - Street 2:SUITE 101
Practice Address - City:MCKINNEY
Practice Address - State:TX
Practice Address - Zip Code:75070-6506
Practice Address - Country:US
Practice Address - Phone:972-547-0047
Practice Address - Fax:972-547-0065
Is Sole Proprietor?:No
Enumeration Date:2006-05-13
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL8866207XX0004X, 207X00000X
MDD0067381207X00000X
VA0101243178207XX0004X
IN01061381A207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XX0004XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryFoot and Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX6512550001OtherDME PTAN
TXL8866OtherLICENSE
2454999OtherUNITED HEALTHCARE
TXP01047820OtherRAILROAD MEDICARE PTAN
TX285510801Medicaid
P00658084OtherRAILROAD MEDICARE
TXTXB128126OtherMEDICARE PTAN
TXTXB128126OtherMEDICARE PTAN
0254450002Medicare NSC
TXTXB128126OtherMEDICARE PTAN
2180003OtherMAMSI
0101243178OtherVA LICENSE
130774ZAKWOtherMEDICARE MARYLAND PTAN
P00658084OtherRAILROAD MEDICARE
0254450002Medicare NSC