Provider Demographics
NPI:1487972964
Name:GRAMZE, NICKALAUS LANE (MD)
Entity type:Individual
Prefix:
First Name:NICKALAUS
Middle Name:LANE
Last Name:GRAMZE
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 1:6565 FANNIN ST
Mailing Address - Street 2:SUITE 1003
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77030-2703
Mailing Address - Country:US
Mailing Address - Phone:713-441-1100
Mailing Address - Fax:
Practice Address - Street 1:755 E MCDOWELL RD FL 4
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85006-2506
Practice Address - Country:US
Practice Address - Phone:602-521-3144
Practice Address - Fax:602-521-3661
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-10
Last Update Date:2021-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN4437207R00000X, 207RC0000X, 208000000X, 208M00000X
AZN4437207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX358659602Medicaid
TX8FW349OtherBLUE CROSS BLUE SHIELD
TX358659601Medicaid
TX8FW348OtherBCBS
TX358659602Medicaid
TX8FW348OtherBCBS