Provider Demographics
NPI:1942383740
Name:NICKELBERRY, BAMBI L (MD)
Entity Type:Individual
Prefix:
First Name:BAMBI
Middle Name:L
Last Name:NICKELBERRY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11486 BURBANK BLVD
Mailing Address - Street 2:
Mailing Address - City:NORTH HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:91601-2301
Mailing Address - Country:US
Mailing Address - Phone:818-505-9991
Mailing Address - Fax:818-505-1331
Practice Address - Street 1:11486 BURBANK BLVD
Practice Address - Street 2:
Practice Address - City:NORTH HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:91601-2301
Practice Address - Country:US
Practice Address - Phone:818-505-9991
Practice Address - Fax:818-505-1331
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-23
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG46679207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
A50458Medicare UPIN
CAWG46679BMedicare PIN