Healthcare Provider Details

I. General information

NPI: 1467031492
Provider Name (Legal Business Name): VINCENT MICHAEL NICCHI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/06/2021
Last Update Date: 08/03/2024
Certification Date: 08/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1441 EASTLAKE AVENUE NTT 3470
LOS ANGELES CA
90033-1019
US

IV. Provider business mailing address

2160 S 1ST AVE
MAYWOOD IL
60153-3328
US

V. Phone/Fax

Practice location:
  • Phone: 323-865-3913
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License NumberA195208
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: