Provider Demographics
NPI:1609850569
Name:KICKLITER, DAVID J (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:J
Last Name:KICKLITER
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 1:407 4TH ST
Mailing Address - Street 2:
Mailing Address - City:NEWPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37821-3755
Mailing Address - Country:US
Mailing Address - Phone:423-623-6240
Mailing Address - Fax:423-623-0102
Practice Address - Street 1:407 4TH ST
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:TN
Practice Address - Zip Code:37821-3755
Practice Address - Country:US
Practice Address - Phone:423-623-6240
Practice Address - Fax:423-623-0102
Is Sole Proprietor?:No
Enumeration Date:2005-12-05
Last Update Date:2013-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN17859207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3028740Medicaid
TN103I087301Medicare PIN
A99269Medicare UPIN
3028743Medicare ID - Type Unspecified