Provider Demographics
NPI:1497249205
Name:NICKSIC, VICTORIA BROCKSMITH (MD)
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:BROCKSMITH
Last Name:NICKSIC
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:VICTORIA
Other - Middle Name:MARIE
Other - Last Name:BROCKSMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6710 WOODGATE RD
Mailing Address - Street 2:
Mailing Address - City:MIDDLETON
Mailing Address - State:WI
Mailing Address - Zip Code:53562-3817
Mailing Address - Country:US
Mailing Address - Phone:812-830-8283
Mailing Address - Fax:
Practice Address - Street 1:6710 WOODGATE RD
Practice Address - Street 2:
Practice Address - City:MIDDLETON
Practice Address - State:WI
Practice Address - Zip Code:53562-3817
Practice Address - Country:US
Practice Address - Phone:812-830-8283
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-15
Last Update Date:2022-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI72629208000000X, 2080N0001X, 208M00000X, 2080P0205X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0205XAllopathic & Osteopathic PhysiciansPediatricsPediatric Endocrinology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program