Provider Demographics
NPI:1235130469
Name:NICLES, KARL F (MD)
Entity Type:Individual
Prefix:
First Name:KARL
Middle Name:F
Last Name:NICLES
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 1:15455 148TH AVE
Mailing Address - Street 2:
Mailing Address - City:SPRING LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:49456-9303
Mailing Address - Country:US
Mailing Address - Phone:616-844-1576
Mailing Address - Fax:
Practice Address - Street 1:3535 PARK ST
Practice Address - Street 2:SUITE 101
Practice Address - City:NORTON SHORES
Practice Address - State:MI
Practice Address - Zip Code:49444-3736
Practice Address - Country:US
Practice Address - Phone:231-737-0411
Practice Address - Fax:231-739-8502
Is Sole Proprietor?:No
Enumeration Date:2005-08-10
Last Update Date:2013-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301069765208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4182350Medicaid
MIH18284Medicare UPIN
MI4182350Medicaid