Provider Demographics
NPI:1508812207
Name:CHERRY, NICOLA J (MD)
Entity Type:Individual
Prefix:DR
First Name:NICOLA
Middle Name:J
Last Name:CHERRY
Suffix:
Gender:F
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:PO BOX 5109
Mailing Address - Street 2:
Mailing Address - City:KLAMATH FALLS
Mailing Address - State:OR
Mailing Address - Zip Code:97601-0119
Mailing Address - Country:US
Mailing Address - Phone:541-882-1540
Mailing Address - Fax:541-882-2583
Practice Address - Street 1:2580 DAGGETT AVE
Practice Address - Street 2:
Practice Address - City:KLAMATH FALLS
Practice Address - State:OR
Practice Address - Zip Code:97601-1127
Practice Address - Country:US
Practice Address - Phone:541-884-1224
Practice Address - Fax:541-884-8030
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-25
Last Update Date:2013-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD21778208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR288475Medicaid
OR115206Medicare ID - Type Unspecified
ORH16843Medicare UPIN