MEDICARE: DR. CARROLL JOHN NICKLE D.O.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2083A0100X	Aerospace Medicine Physician	19464	CO

General Provider Information

NPI Number	:	1497757108
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CARROLL JOHN NICKLE D.O.

Provider Business Mailing Address
First Line	:	1224 CHATTINGHAM DR
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23464-5836
Country	:	US
Telephone Number	:	757-495-2719
Fax Number	:

Provider Business Practice Location Address
First Line	:	1224 CHATTINGHAM DR
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23464-5836
Country	:	US
Telephone Number	:	757-495-2719
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/12/2005
Last Update Date	:	07/08/2007

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