Provider Demographics
NPI:1134357239
Name:NICKEL, MARSHALL (MD)
Entity type:Individual
Prefix:DR
First Name:MARSHALL
Middle Name:
Last Name:NICKEL
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 1:50 W BROADWAY STE 333 #164321
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84101-2027
Mailing Address - Country:US
Mailing Address - Phone:801-709-1470
Mailing Address - Fax:253-218-6964
Practice Address - Street 1:50 W BROADWAY STE 333 #164321
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84101-2027
Practice Address - Country:US
Practice Address - Phone:801-709-1470
Practice Address - Fax:253-218-6964
Is Sole Proprietor?:No
Enumeration Date:2009-06-26
Last Update Date:2025-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD60216841207Q00000X
IDM-13326207Q00000X
NC2011-01336207Q00000X
UT9849340-1205207Q00000X, 208M00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG8942212Medicare PIN