Provider Demographics
NPI:1598748725
Name:NICKISCH, FLORIAN (MD)
Entity Type:Individual
Prefix:DR
First Name:FLORIAN
Middle Name:
Last Name:NICKISCH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:590 WAKARA WAY
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84108-1200
Mailing Address - Country:US
Mailing Address - Phone:801-587-5486
Mailing Address - Fax:801-587-5411
Practice Address - Street 1:590 WAKARA WAY
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84108-1200
Practice Address - Country:US
Practice Address - Phone:801-587-5486
Practice Address - Fax:801-587-5411
Is Sole Proprietor?:No
Enumeration Date:2005-11-22
Last Update Date:2021-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2005-01034207X00000X
UT6475000-1205207XX0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0004XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryFoot and Ankle Surgery
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCN0103AMedicaid
NC5901362Medicaid
NCI17743Medicare UPIN
SCN0103AMedicaid