Provider Demographics
NPI:1134115926
Name:SHEROCK, NICHOLAS E JR (DO)
Entity Type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:E
Last Name:SHEROCK
Suffix:JR
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 1:830 S MAIN ST
Mailing Address - Street 2:#102
Mailing Address - City:ORRVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44667
Mailing Address - Country:US
Mailing Address - Phone:330-765-9104
Mailing Address - Fax:330-682-0747
Practice Address - Street 1:830 S MAIN ST
Practice Address - Street 2:#102
Practice Address - City:ORRVILLE
Practice Address - State:OH
Practice Address - Zip Code:44667
Practice Address - Country:US
Practice Address - Phone:330-765-9104
Practice Address - Fax:330-682-0747
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-27
Last Update Date:2013-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34005035174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0976250Medicaid
OHF80353Medicare UPIN
OHSH0760681Medicare ID - Type Unspecified