Provider Demographics
NPI:1437544582
Name:BLICKENSTAFF, NICHOLAS (MD, MS)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:
Last Name:BLICKENSTAFF
Suffix:
Gender:M
Credentials:MD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7123 W ARCHER AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60638-2203
Mailing Address - Country:US
Mailing Address - Phone:708-634-4602
Mailing Address - Fax:630-495-1770
Practice Address - Street 1:6454 W EMERALD ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-8734
Practice Address - Country:US
Practice Address - Phone:208-377-0820
Practice Address - Fax:208-375-8046
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-04
Last Update Date:2022-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.150002207N00000X
IDM15699207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty