Provider Demographics
NPI:1609064070
Name:HALICKI, NESTOR (DO)
Entity Type:Individual
Prefix:
First Name:NESTOR
Middle Name:
Last Name:HALICKI
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 1:551 LINN ST
Mailing Address - Street 2:
Mailing Address - City:ALLEGAN
Mailing Address - State:MI
Mailing Address - Zip Code:49010-1595
Mailing Address - Country:US
Mailing Address - Phone:269-686-5800
Mailing Address - Fax:269-686-5899
Practice Address - Street 1:5616 HIGHLAND RD
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:MI
Practice Address - Zip Code:48327-1926
Practice Address - Country:US
Practice Address - Phone:248-674-2273
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-10
Last Update Date:2018-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101009374207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1735036Medicaid
MI56301542081Medicare PIN
MI1735036Medicaid