Provider Demographics
NPI:1750681391
Name:FICKENSCHER, KEVIN MICHAEL SR (MD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:MICHAEL
Last Name:FICKENSCHER
Suffix:SR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:7710 WOODMONT AVENUE
Mailing Address - Street 2:SUITE 211
Mailing Address - City:BETHESDA
Mailing Address - State:MD
Mailing Address - Zip Code:20814
Mailing Address - Country:US
Mailing Address - Phone:415-450-1515
Mailing Address - Fax:
Practice Address - Street 1:3499 NW BRAID DRIVE
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-8682
Practice Address - Country:US
Practice Address - Phone:415-307-7358
Practice Address - Fax:415-223-9383
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-29
Last Update Date:2023-03-07
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CAG84904207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG84904OtherCALIFORNIA STATE MEDICAL BOARD
BF6129200OtherDRUG ENFORCEMENT AGENCY