Provider Demographics
NPI:1679520837
Name:NICKELS, MARK W (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:W
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 1:101 RIVERFRONT BLVD STE 710
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34205-8812
Mailing Address - Country:US
Mailing Address - Phone:941-776-4000
Mailing Address - Fax:
Practice Address - Street 1:12271 US HIGHWAY 301 N
Practice Address - Street 2:
Practice Address - City:PARRISH
Practice Address - State:FL
Practice Address - Zip Code:34219-8410
Practice Address - Country:US
Practice Address - Phone:941-776-4050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-30
Last Update Date:2023-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME152102207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine