Provider Demographics
NPI:1861473589
Name:NICKELSON, KIM (MD)
Entity Type:Individual
Prefix:DR
First Name:KIM
Middle Name:
Last Name:NICKELSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6101 BLUE LAGOON DR STE 200
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33126-3168
Mailing Address - Country:US
Mailing Address - Phone:305-500-2000
Mailing Address - Fax:
Practice Address - Street 1:301 NW 84TH AVE STE 101
Practice Address - Street 2:
Practice Address - City:PLANTATION
Practice Address - State:FL
Practice Address - Zip Code:33324-1807
Practice Address - Country:US
Practice Address - Phone:954-581-1900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-09
Last Update Date:2022-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA50822207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
D50962Medicare UPIN
04227WMedicare ID - Type Unspecified