Provider Demographics
NPI:1073558565
Name:NICOLL-MERSON, HEIDI GAYLE (MD)
Entity Type:Individual
Prefix:
First Name:HEIDI
Middle Name:GAYLE
Last Name:NICOLL-MERSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:HEIDI
Other - Middle Name:GAYLE
Other - Last Name:NICOLL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:210 N TUSTIN AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92705-3807
Mailing Address - Country:US
Mailing Address - Phone:714-347-1010
Mailing Address - Fax:714-647-1245
Practice Address - Street 1:481 30TH ST
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94609-3209
Practice Address - Country:US
Practice Address - Phone:510-835-4521
Practice Address - Fax:510-835-4223
Is Sole Proprietor?:No
Enumeration Date:2006-06-18
Last Update Date:2017-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG56098207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G560980Medicaid
E24857Medicare UPIN
CA00G560980Medicare PIN