Healthcare Provider Details

I. General information

NPI: 1649215245
Provider Name (Legal Business Name): RACHEL MIRIAM NIKNAM MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2006
Last Update Date: 09/02/2020
Certification Date: 09/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 WALNUT ST STE 210W
PHILADELPHIA PA
19106-3323
US

IV. Provider business mailing address

601 WALNUT ST STE 210W
PHILADELPHIA PA
19106-3323
US

V. Phone/Fax

Practice location:
  • Phone: 215-925-6402
  • Fax: 215-925-0262
Mailing address:
  • Phone: 215-925-6402
  • Fax: 215-925-0262

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207WX0009X
TaxonomyGlaucoma Specialist (Ophthalmology) Physician
License NumberMD428282
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberMD428282
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: