Provider Demographics
NPI:1215089891
Name:REID, NICOLE LESLEY (MD)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:LESLEY
Last Name:REID
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:PO BOX 844658
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-4658
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2601 THORNTON LN
Practice Address - Street 2:
Practice Address - City:TEMPLE
Practice Address - State:TX
Practice Address - Zip Code:76502-1808
Practice Address - Country:US
Practice Address - Phone:254-724-2111
Practice Address - Fax:254-235-1056
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2024-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2007011080208600000X
TXP7553208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP7553OtherMEDICARE
NC140GNOtherBCBS NC
NC5901629Medicaid
NC140GNOtherBCBS NC