Healthcare Provider Details

I. General information

NPI: 1114214004
Provider Name (Legal Business Name): NICKOLAS S DEMARK DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2011
Last Update Date: 09/11/2025
Certification Date: 09/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1229 C AVE E
OSKALOOSA IA
52577-4298
US

IV. Provider business mailing address

1229 C AVE E
OSKALOOSA IA
52577-4298
US

V. Phone/Fax

Practice location:
  • Phone: 641-672-3100
  • Fax:
Mailing address:
  • Phone: 641-672-3236
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number5101019580
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number62482
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number62482
License Number StateWI
# 4
Primary TaxonomyY
Taxonomy Code207RH0002X
TaxonomyHospice and Palliative Medicine (Internal Medicine) Physician
License NumberDO-06639
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: