Provider Demographics
NPI:1801010475
Name:NICCOLE, MICHAEL WAYNE (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:WAYNE
Last Name:NICCOLE
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 1:1101 BAYSIDE DRIVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92625
Mailing Address - Country:US
Mailing Address - Phone:949-718-6900
Mailing Address - Fax:949-718-9367
Practice Address - Street 1:1101 BAYSIDE DRIVE
Practice Address - Street 2:SUITE 100
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92625
Practice Address - Country:US
Practice Address - Phone:949-718-6900
Practice Address - Fax:949-718-9367
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA30397174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA26098Medicare UPIN