Healthcare Provider Details

I. General information

NPI: 1467412510
Provider Name (Legal Business Name): RICHARD A. NICKLAS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2006
Last Update Date: 01/03/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1830 TOWN CENTER DR SUITE #206
RESTON VA
20190-3236
US

IV. Provider business mailing address

8318 ARLINGTON BLVD SUITE #308
FAIRFAX VA
22031-5218
US

V. Phone/Fax

Practice location:
  • Phone: 703-437-5151
  • Fax: 703-280-4650
Mailing address:
  • Phone: 703-573-4440
  • Fax: 703-280-4650

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207KA0200X
TaxonomyAllergy Physician
License NumberMD3203
License Number StateDC
# 2
Primary TaxonomyY
Taxonomy Code207KA0200X
TaxonomyAllergy Physician
License Number0101025325
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: