Healthcare Provider Details

I. General information

NPI: 1215963160
Provider Name (Legal Business Name): ROBERT E NICKEL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2006
Last Update Date: 04/05/2022
Certification Date: 04/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 E. 18TH ST
EUGENE OR
97403-5254
US

IV. Provider business mailing address

901 E. 18TH ST
EUGENE OR
97403-5254
US

V. Phone/Fax

Practice location:
  • Phone: 541-346-3575
  • Fax: 541-346-5844
Mailing address:
  • Phone: 541-346-3575
  • Fax: 541-346-5844

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD12325
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code2080P0006X
TaxonomyDevelopmental - Behavioral Pediatrics Physician
License NumberMD12325
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier037WCGLPG
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: