Provider Demographics
NPI:1215026521
Name:NICKERSON, BRUCE GREENWOOD (MD)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:GREENWOOD
Last Name:NICKERSON
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 1:455 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92868-3835
Mailing Address - Country:US
Mailing Address - Phone:714-289-4511
Mailing Address - Fax:714-289-4788
Practice Address - Street 1:455 S MAIN ST
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-3835
Practice Address - Country:US
Practice Address - Phone:714-532-8620
Practice Address - Fax:714-289-4072
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2008-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG388432080N0001X, 2080P0214X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0214XAllopathic & Osteopathic PhysiciansPediatricsPediatric Pulmonology
No2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G388430Medicaid
CAWG38843FOtherMEDICARE PTAN
CAWG38843FOtherMEDICARE PTAN