Provider Demographics
NPI:1013155480
Name:NICOLE REED MEDICAL, PLLC
Entity Type:Organization
Organization Name:NICOLE REED MEDICAL, PLLC
Other - Org Name:CENTER FOR DERMATOLOGY & COSMETIC LASER SURGERY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:BRAD
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-985-9003
Mailing Address - Street 1:5044 TENNYSON PKWY
Mailing Address - Street 2:STE B
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75024-2952
Mailing Address - Country:US
Mailing Address - Phone:972-985-9003
Mailing Address - Fax:972-985-1176
Practice Address - Street 1:5044 TENNYSON PKWY
Practice Address - Street 2:STE B
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75024-2952
Practice Address - Country:US
Practice Address - Phone:972-985-9003
Practice Address - Fax:972-985-1176
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-23
Last Update Date:2012-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL4702207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0A3547Medicare UPIN