Provider Demographics
NPI:1457466112
Name:NICEWANDER, ROBERT K (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:K
Last Name:NICEWANDER
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 1:30 HARRIS AVE
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:RI
Mailing Address - Zip Code:02865-4314
Mailing Address - Country:US
Mailing Address - Phone:781-906-6870
Mailing Address - Fax:
Practice Address - Street 1:1126 HARTFORD AVE
Practice Address - Street 2:
Practice Address - City:JOHNSTON
Practice Address - State:RI
Practice Address - Zip Code:02919-7130
Practice Address - Country:US
Practice Address - Phone:401-351-2750
Practice Address - Fax:401-351-6613
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA223931207Q00000X
RIMD11252207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
C98001Medicare UPIN
5N312Medicare ID - Type Unspecified