Provider Demographics
NPI:1104881432
Name:NICKMAN, STEVEN LOUIS (MD)
Entity type:Individual
Prefix:DR
First Name:STEVEN
Middle Name:LOUIS
Last Name:NICKMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26 HOLLY LN APT 2B
Mailing Address - Street 2:
Mailing Address - City:CHESTNUT HILL
Mailing Address - State:MA
Mailing Address - Zip Code:02467-2155
Mailing Address - Country:US
Mailing Address - Phone:617-734-3016
Mailing Address - Fax:617-739-8286
Practice Address - Street 1:26 HOLLY LN APT 2B
Practice Address - Street 2:
Practice Address - City:CHESTNUT HILL
Practice Address - State:MA
Practice Address - Zip Code:02467-2155
Practice Address - Country:US
Practice Address - Phone:617-734-3016
Practice Address - Fax:617-739-8286
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-19
Last Update Date:2022-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA32763208000000X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2012847Medicaid
MA032763OtherTUFTS HEALTH PLAN
MAB11394Medicare ID - Type Unspecified
MA2012847Medicaid