Provider Demographics
NPI:1144356460
Name:NICKLE, HARRY HERMAN (MD)
Entity type:Individual
Prefix:
First Name:HARRY
Middle Name:HERMAN
Last Name:NICKLE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1001 N MARTEL AVE
Mailing Address - Street 2:
Mailing Address - City:WEST HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90046-6611
Mailing Address - Country:US
Mailing Address - Phone:323-436-5019
Mailing Address - Fax:323-337-9142
Practice Address - Street 1:1669 W AVENUE J
Practice Address - Street 2:SUITE 301
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93534-2866
Practice Address - Country:US
Practice Address - Phone:661-723-3244
Practice Address - Fax:661-723-3504
Is Sole Proprietor?:No
Enumeration Date:2007-02-23
Last Update Date:2013-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG45071207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAC96781Medicare UPIN
CAWG45071BMedicare ID - Type Unspecified