Basic Information
Provider Information | |||||||||
NPI: | 1215963160 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | NICKEL | ||||||||
FirstName: | ROBERT | ||||||||
MiddleName: | E | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 901 E. 18TH ST | ||||||||
Address2: |   | ||||||||
City: | EUGENE | ||||||||
State: | OR | ||||||||
PostalCode: | 974035254 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5413463575 | ||||||||
FaxNumber: | 5413465844 | ||||||||
Practice Location | |||||||||
Address1: | 901 E. 18TH ST | ||||||||
Address2: |   | ||||||||
City: | EUGENE | ||||||||
State: | OR | ||||||||
PostalCode: | 974035254 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5413463575 | ||||||||
FaxNumber: | 5413465844 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/23/2006 | ||||||||
LastUpdateDate: | 04/05/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 04/05/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | MD12325 | OR | N |   | Allopathic & Osteopathic Physicians | Pediatrics |   | 2080P0006X | MD12325 | OR | Y |   | Allopathic & Osteopathic Physicians | Pediatrics | Developmental – Behavioral Pediatrics |
ID Information
ID | Type | State | Issuer | Description | 037WCGLPG | 05 | OR |   | MEDICAID |