Provider Demographics
NPI:1467412510
Name:NICKLAS, RICHARD A (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:A
Last Name:NICKLAS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:8318 ARLINGTON BLVD
Mailing Address - Street 2:SUITE #308
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22031-5218
Mailing Address - Country:US
Mailing Address - Phone:703-573-4440
Mailing Address - Fax:703-280-4650
Practice Address - Street 1:1830 TOWN CENTER DR
Practice Address - Street 2:SUITE #206
Practice Address - City:RESTON
Practice Address - State:VA
Practice Address - Zip Code:20190-3236
Practice Address - Country:US
Practice Address - Phone:703-437-5151
Practice Address - Fax:703-280-4650
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2012-01-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
DCMD3203207KA0200X
VA0101025325207KA0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207KA0200XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyAllergy
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA017654R25Medicare PIN
B93786Medicare UPIN