Provider Demographics
NPI:1720107824
Name:NUSSBAUM, NICHOLAS LEE (MD)
Entity Type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:LEE
Last Name:NUSSBAUM
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 1:205 TOWER DR
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:IN
Mailing Address - Zip Code:46772-9362
Mailing Address - Country:US
Mailing Address - Phone:260-692-6163
Mailing Address - Fax:260-728-3949
Practice Address - Street 1:205 TOWER DR
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:IN
Practice Address - Zip Code:46772-9362
Practice Address - Country:US
Practice Address - Phone:260-692-6163
Practice Address - Fax:260-728-3949
Is Sole Proprietor?:No
Enumeration Date:2007-03-28
Last Update Date:2012-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01063067A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200970670Medicaid
IN200970670Medicaid