Provider Demographics
NPI:1255390050
Name:NICKLES, DEAN JOHN (MD)
Entity type:Individual
Prefix:
First Name:DEAN
Middle Name:JOHN
Last Name:NICKLES
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 1:5800 HOLLIS ST
Mailing Address - Street 2:
Mailing Address - City:EMERYVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:94608-2016
Mailing Address - Country:US
Mailing Address - Phone:510-806-2100
Mailing Address - Fax:510-806-2548
Practice Address - Street 1:5800 HOLLIS ST
Practice Address - Street 2:
Practice Address - City:EMERYVILLE
Practice Address - State:CA
Practice Address - Zip Code:94608-2016
Practice Address - Country:US
Practice Address - Phone:510-806-2100
Practice Address - Fax:510-806-2548
Is Sole Proprietor?:No
Enumeration Date:2006-03-21
Last Update Date:2024-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG44039207RC0200X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
A49531Medicare UPIN