Provider Demographics
NPI:1295925535
Name:NICKLAS, JEFFREY SCOTT (MD)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:SCOTT
Last Name:NICKLAS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4135 BOARDMAN CANFIELD RD STE 101
Mailing Address - Street 2:
Mailing Address - City:CANFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44406-9803
Mailing Address - Country:US
Mailing Address - Phone:330-286-5330
Mailing Address - Fax:330-286-5396
Practice Address - Street 1:1044 BELMONT AVE
Practice Address - Street 2:
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44504-1006
Practice Address - Country:US
Practice Address - Phone:330-480-3658
Practice Address - Fax:330-286-5396
Is Sole Proprietor?:No
Enumeration Date:2007-08-01
Last Update Date:2020-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT190045207L00000X
PAMD443825207L00000X
OH35.066875207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH4119641OtherMEDICARE PTAN
11176372OtherCAQH
OH0056821Medicaid
PA227307OtherMEDICARE PTAN