Healthcare Provider Details

I. General information

NPI: 1760415525
Provider Name (Legal Business Name): NICOLA J CHERRY MD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/07/2006
Last Update Date: 08/21/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2580 DAGGETT AVE
KLAMATH FALLS OR
97601-1127
US

IV. Provider business mailing address

PO BOX 1359
KLAMATH FALLS OR
97601-0075
US

V. Phone/Fax

Practice location:
  • Phone: 541-884-1224
  • Fax:
Mailing address:
  • Phone: 541-882-1540
  • Fax: 541-882-2583

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD21778
License Number StateOR

VII. Legacy identifiers

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

# 1
Identifier288475
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer

VIII. Authorized Official

Name: NICOLA J CHERRY
Title or Position: OWNER
Credential: M.D.
Phone: 541-884-1224