Healthcare Provider Details

I. General information

NPI: 1720107824
Provider Name (Legal Business Name): NICHOLAS LEE NUSSBAUM M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2007
Last Update Date: 04/03/2026
Certification Date: 04/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1819 CAREW ST
FORT WAYNE IN
46805-4705
US

IV. Provider business mailing address

205 TOWER DR
MONROE IN
46772-9362
US

V. Phone/Fax

Practice location:
  • Phone: 260-373-7770
  • Fax: 260-373-7775
Mailing address:
  • Phone: 260-692-6163
  • Fax: 260-728-3949

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number01063067A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: