Healthcare Provider Details

I. General information

NPI: 1154302354
Provider Name (Legal Business Name): TIMOTHY J NICKEL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/07/2005
Last Update Date: 03/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9311 S MINGO RD
TULSA OK
74133-5702
US

IV. Provider business mailing address

9311 S MINGO RD
TULSA OK
74133-5702
US

V. Phone/Fax

Practice location:
  • Phone: 918-307-1613
  • Fax: 918-307-2454
Mailing address:
  • Phone: 918-307-1613
  • Fax: 918-307-2454

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207KA0200X
TaxonomyAllergy Physician
License Number23866
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: