Provider Demographics
NPI:1902112089
Name:NIX, MICAH DOUGLASS (DO)
Entity Type:Individual
Prefix:
First Name:MICAH
Middle Name:DOUGLASS
Last Name:NIX
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:613 S SHAWNEE ST
Mailing Address - Street 2:
Mailing Address - City:SKIATOOK
Mailing Address - State:OK
Mailing Address - Zip Code:74070-1886
Mailing Address - Country:US
Mailing Address - Phone:918-706-4575
Mailing Address - Fax:
Practice Address - Street 1:613 S SHAWNEE ST
Practice Address - Street 2:
Practice Address - City:SKIATOOK
Practice Address - State:OK
Practice Address - Zip Code:74070-1886
Practice Address - Country:US
Practice Address - Phone:918-706-4575
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-26
Last Update Date:2012-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200397460AMedicaid
OK200397460AMedicaid