Provider Demographics
NPI:1841211950
Name:OMDAHL, NICHOLAS (MD)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:
Last Name:OMDAHL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3803 SPRING ST
Mailing Address - Street 2:SUITE 600
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53405-1660
Mailing Address - Country:US
Mailing Address - Phone:262-687-8312
Mailing Address - Fax:262-687-8796
Practice Address - Street 1:3803 SPRING ST
Practice Address - Street 2:SUITE 600
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53405-1660
Practice Address - Country:US
Practice Address - Phone:262-687-8312
Practice Address - Fax:262-687-8796
Is Sole Proprietor?:No
Enumeration Date:2006-07-22
Last Update Date:2010-09-16
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
WI20631207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIB55507Medicare UPIN