Provider Demographics
NPI:1598977597
Name:NICKELS, RUSSELL ARTHUR (MD)
Entity Type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:ARTHUR
Last Name:NICKELS
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 1:415 HIGHLAND AVE.
Mailing Address - Street 2:
Mailing Address - City:SMITH RIVER
Mailing Address - State:CA
Mailing Address - Zip Code:95567
Mailing Address - Country:US
Mailing Address - Phone:707-487-2211
Mailing Address - Fax:707-487-2211
Practice Address - Street 1:415 HIGHLAND AVE.
Practice Address - Street 2:
Practice Address - City:SMITH RIVER
Practice Address - State:CA
Practice Address - Zip Code:95567
Practice Address - Country:US
Practice Address - Phone:707-487-2211
Practice Address - Fax:707-487-2211
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA00C306750208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00C306750OtherMEDICAL LICENSE NUMBER
CA00C306750OtherMEDICAL LICENSE NUMBER