Provider Demographics
NPI:1790707966
Name:NICKODEM, ROBERT J JR (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:J
Last Name:NICKODEM
Suffix:JR
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 1:7060 WAYSIDE DR
Mailing Address - Street 2:MTR1/-102
Mailing Address - City:MENTOR
Mailing Address - State:OH
Mailing Address - Zip Code:44060-6527
Mailing Address - Country:US
Mailing Address - Phone:440-357-2770
Mailing Address - Fax:440-354-4669
Practice Address - Street 1:7060 WAYSIDE DR
Practice Address - Street 2:MTR1/-102
Practice Address - City:MENTOR
Practice Address - State:OH
Practice Address - Zip Code:44060-6527
Practice Address - Country:US
Practice Address - Phone:440-357-2770
Practice Address - Fax:440-354-4669
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2013-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-05-1872-N207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0594110Medicaid
OH0594110Medicaid
OHA16171Medicare UPIN