Provider Demographics
NPI:1831452580
Name:NICKOLI, MICHAEL STEPHEN (MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:STEPHEN
Last Name:NICKOLI
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 1:5450 FRANTZ RD STE 360
Mailing Address - Street 2:
Mailing Address - City:DUBLIN
Mailing Address - State:OH
Mailing Address - Zip Code:43016-4141
Mailing Address - Country:US
Mailing Address - Phone:614-533-6497
Mailing Address - Fax:614-544-6370
Practice Address - Street 1:130 MORRIS RD
Practice Address - Street 2:
Practice Address - City:CIRCLEVILLE
Practice Address - State:OH
Practice Address - Zip Code:43113-1362
Practice Address - Country:US
Practice Address - Phone:740-477-6511
Practice Address - Fax:740-477-6888
Is Sole Proprietor?:No
Enumeration Date:2012-06-18
Last Update Date:2022-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125061743207X00000X
390200000X
OH35.133935207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0310959Medicaid