Provider Demographics
NPI:1801899760
Name:OLDENBURG, NICKLAS B (MD)
Entity type:Individual
Prefix:DR
First Name:NICKLAS
Middle Name:B
Last Name:OLDENBURG
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 1:825 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02904-5707
Mailing Address - Country:US
Mailing Address - Phone:401-521-9700
Mailing Address - Fax:401-751-1686
Practice Address - Street 1:825 N MAIN ST
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02904-5707
Practice Address - Country:US
Practice Address - Phone:401-521-9700
Practice Address - Fax:401-751-1686
Is Sole Proprietor?:No
Enumeration Date:2005-05-24
Last Update Date:2016-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI109312085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI920007190OtherRR MEDICARE
MA110000497AMedicaid
RI7009934Medicaid
RI7009935Medicare PIN
RI007000161Medicare PIN
RI920007190OtherRR MEDICARE
H21239Medicare UPIN
MA110000497AMedicaid