Provider Demographics
NPI:1710070412
Name:NICKLES, LEROY (MD)
Entity Type:Individual
Prefix:DR
First Name:LEROY
Middle Name:
Last Name:NICKLES
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 1:870 SAINT NICHOLAS AVE APT D8
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10032-5273
Mailing Address - Country:US
Mailing Address - Phone:212-491-8725
Mailing Address - Fax:212-491-8725
Practice Address - Street 1:170 W 12TH ST
Practice Address - Street 2:EMERGENCY DEPT ADMINISTRATION
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10011-8202
Practice Address - Country:US
Practice Address - Phone:212-604-2590
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2024-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD425081207P00000X
MI4301511279207P00000X
NY236503207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYI21951Medicare UPIN
NY02678462Medicare ID - Type UnspecifiedNY MEDICAID
NY554APRMedicare ID - Type UnspecifiedGHI MEDICARE