Provider Demographics
NPI:1639267040
Name:NIKICICZ, EDWARD PETER (MD)
Entity type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:PETER
Last Name:NIKICICZ
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 1:3908 MCTYRES COVE CT
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23112-4665
Mailing Address - Country:US
Mailing Address - Phone:804-744-6140
Mailing Address - Fax:
Practice Address - Street 1:801 S ADAMS ST
Practice Address - Street 2:SRMC, LAB
Practice Address - City:PETERSBURG
Practice Address - State:VA
Practice Address - Zip Code:23803-5149
Practice Address - Country:US
Practice Address - Phone:804-862-5028
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-11
Last Update Date:2009-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAVA0101047885207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA086358OtherBCBS
VA6600727Medicaid
VA6600727Medicaid
VAF26595Medicare UPIN