Provider Demographics
NPI:1497716971
Name:NICCOLI, JEFFREY JOSEPH (DPM)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:JOSEPH
Last Name:NICCOLI
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2225 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:ALAMEDA
Mailing Address - State:CA
Mailing Address - Zip Code:94501
Mailing Address - Country:US
Mailing Address - Phone:510-521-3410
Mailing Address - Fax:510-521-2521
Practice Address - Street 1:2225 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:ALAMEDA
Practice Address - State:CA
Practice Address - Zip Code:94501
Practice Address - Country:US
Practice Address - Phone:510-521-3410
Practice Address - Fax:510-521-2521
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-01
Last Update Date:2015-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE3781213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA000E37810OtherMEDICARE
CA000E37810OtherMEDICARE