Provider Demographics
NPI:1497757108
Name:NICKLE, CARROLL JOHN (DO)
Entity Type:Individual
Prefix:DR
First Name:CARROLL
Middle Name:JOHN
Last Name:NICKLE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1224 CHATTINGHAM DR
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23464-5836
Mailing Address - Country:US
Mailing Address - Phone:757-495-2719
Mailing Address - Fax:
Practice Address - Street 1:1224 CHATTINGHAM DR
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23464-5836
Practice Address - Country:US
Practice Address - Phone:757-495-2719
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO194642083A0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083A0100XAllopathic & Osteopathic PhysiciansPreventive MedicineAerospace Medicine