Healthcare Provider Details

I. General information

NPI: 1235130469
Provider Name (Legal Business Name): KARL F NICLES M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/10/2005
Last Update Date: 02/21/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3535 PARK ST SUITE 101
NORTON SHORES MI
49444-3736
US

IV. Provider business mailing address

15455 148TH AVE
SPRING LAKE MI
49456-9303
US

V. Phone/Fax

Practice location:
  • Phone: 231-737-0411
  • Fax: 231-739-8502
Mailing address:
  • Phone: 616-844-1576
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301069765
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: