Provider Demographics
NPI:1770572760
Name:NICKAS, MICHAEL EDWARD
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:EDWARD
Last Name:NICKAS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20055 LAKE CHABOT RD
Mailing Address - Street 2:#100
Mailing Address - City:CASTRO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:94546-5331
Mailing Address - Country:US
Mailing Address - Phone:510-889-0270
Mailing Address - Fax:510-889-8954
Practice Address - Street 1:20055 LAKE CHABOT RD
Practice Address - Street 2:#100
Practice Address - City:CASTRO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:94546-5331
Practice Address - Country:US
Practice Address - Phone:510-889-0270
Practice Address - Fax:510-889-8954
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-21
Last Update Date:2007-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG70673208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
00G706730Medicare ID - Type Unspecified
F33675Medicare UPIN