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General NPI Number Information
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NPI Number | 1649349283
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Entity Type | Organization
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Legal Business Name | BONNIE NICKEL, M.D,
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Dates
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Enumeration Date | 11/07/2006
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Last Update Date | 10/15/2007
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Provider Practice Location Address
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Address Line | 750 LAS GALLINAS AVE SUITE #114
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City | SAN RAFAEL
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State | CA
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Zip | 94903-3438
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Country | US
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Telephone | 415-492-0950
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Fax | 415-492-9029
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Provider Business Mailing Address
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Address Line | 750 LAS GALLINAS AVE SUITE #114
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City | SAN RAFAEL
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State | CA
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Zip | 94903-3438
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Country | US
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Telephone | 415-492-0950
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Fax | 415-492-9029
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Authorized Official
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Title or Position | OWNER
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Name | DR. BONNIE LYNN NICKEL
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Credential | M.D.
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Telephone | 415-492-0950
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207W00000X
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Taxonomy Name | Ophthalmology Physician
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License Number | 00G362480
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License Number State | CA
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