Provider Demographics
NPI:1972751360
Name:LIN, NICHOLAS (MD)
Entity type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:
Last Name:LIN
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:PO BOX 4890
Mailing Address - Street 2:
Mailing Address - City:VICTORIA
Mailing Address - State:TX
Mailing Address - Zip Code:77903-4890
Mailing Address - Country:US
Mailing Address - Phone:361-574-1858
Mailing Address - Fax:
Practice Address - Street 1:2700 CITIZENS PLZ
Practice Address - Street 2:
Practice Address - City:VICTORIA
Practice Address - State:TX
Practice Address - Zip Code:77901-5754
Practice Address - Country:US
Practice Address - Phone:361-574-1858
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-28
Last Update Date:2016-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXBP10032395207Q00000X
TXN6911207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX207Q00000XMedicaid
TX207Q00000XMedicaid