Provider Demographics
NPI:1760489389
Name:PAIK-NICELY, TIMOTHY CHARLES
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:CHARLES
Last Name:PAIK-NICELY
Suffix:
Gender:M
Credentials:
Other - Prefix:DR
Other - First Name:TIMOTHY
Other - Middle Name:CHARLES
Other - Last Name:NICELY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:2505 LUCAS ST
Mailing Address - Street 2:STE B
Mailing Address - City:EUREKA
Mailing Address - State:CA
Mailing Address - Zip Code:95501-3340
Mailing Address - Country:US
Mailing Address - Phone:707-601-9767
Mailing Address - Fax:707-601-9746
Practice Address - Street 1:2505 LUCAS ST
Practice Address - Street 2:STE B
Practice Address - City:EUREKA
Practice Address - State:CA
Practice Address - Zip Code:95501-3340
Practice Address - Country:US
Practice Address - Phone:707-601-9767
Practice Address - Fax:707-601-9746
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-29
Last Update Date:2023-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG44510207Q00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G445100Medicaid
CA00G445100Medicare PIN
CA00G445101Medicare PIN
CAA49671Medicare UPIN
CABO251ZMedicare PIN
CA00G445102Medicare PIN
CA00G445100Medicaid