Provider Demographics
NPI:1194081414
Name:LINCOLN, CLINT NICKOLAS (MD)
Entity type:Individual
Prefix:
First Name:CLINT
Middle Name:NICKOLAS
Last Name:LINCOLN
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 1:10071 GULF HWY
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70607-8672
Mailing Address - Country:US
Mailing Address - Phone:337-905-2151
Mailing Address - Fax:337-905-2154
Practice Address - Street 1:10071 GULF HWY
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70607
Practice Address - Country:US
Practice Address - Phone:337-905-2151
Practice Address - Fax:337-905-2154
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-11
Last Update Date:2018-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-9199207Q00000X
TXQ3727207Q00000X
LAMD.207591207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX414630YKVAMedicare UPIN