Provider Demographics
NPI:1356347603
Name:FICKLEN, DAVID R
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:R
Last Name:FICKLEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 MEDICAL PARK LN STE A
Mailing Address - Street 2:
Mailing Address - City:HUNTSVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:77340-4975
Mailing Address - Country:US
Mailing Address - Phone:936-435-0014
Mailing Address - Fax:936-435-9108
Practice Address - Street 1:102 MEDICAL PARK LN STE A
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:TX
Practice Address - Zip Code:77340-4975
Practice Address - Country:US
Practice Address - Phone:936-435-0014
Practice Address - Fax:936-435-9108
Is Sole Proprietor?:No
Enumeration Date:2005-06-22
Last Update Date:2011-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK5929207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX047959403Medicaid
8M5490OtherBCBS
G68132Medicare UPIN
00376QMedicare ID - Type Unspecified
TX047959403Medicaid