Healthcare Provider Details

I. General information

NPI: 1144356460
Provider Name (Legal Business Name): HARRY HERMAN NICKLE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/23/2007
Last Update Date: 09/13/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1669 W AVENUE J SUITE 301
LANCASTER CA
93534-2866
US

IV. Provider business mailing address

1001 N MARTEL AVE
WEST HOLLYWOOD CA
90046-6611
US

V. Phone/Fax

Practice location:
  • Phone: 661-723-3244
  • Fax: 661-723-3504
Mailing address:
  • Phone: 323-436-5019
  • Fax: 323-337-9142

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License NumberG45071
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: