Provider Demographics
NPI:1770525602
Name:NIBLETT, KEVIN W (MD)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:W
Last Name:NIBLETT
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 1:3450 W. WHEATLAND ROAD
Mailing Address - Street 2:POB II SUITE 245
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75237-2043
Mailing Address - Country:US
Mailing Address - Phone:972-283-2244
Mailing Address - Fax:972-283-2246
Practice Address - Street 1:3450 W. WHEATLAND ROAD
Practice Address - Street 2:BUILDING II SUITE 245
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75237-2043
Practice Address - Country:US
Practice Address - Phone:972-283-2244
Practice Address - Fax:972-283-2246
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-12
Last Update Date:2020-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ3706208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX105633503Medicaid
TX613557OtherMEDICARE PTAN
TX105633502Medicaid
G03097Medicare UPIN
TX105633502Medicaid
TX613557Medicare PIN