Provider Demographics
NPI:1699762336
Name:NIKKEL, MARK RYAN (DO)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:RYAN
Last Name:NIKKEL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:955 S BAILEY AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH HAVEN
Mailing Address - State:MI
Mailing Address - Zip Code:49090-6743
Mailing Address - Country:US
Mailing Address - Phone:269-637-5271
Mailing Address - Fax:269-639-2818
Practice Address - Street 1:955 S BAILEY AVE
Practice Address - Street 2:
Practice Address - City:SOUTH HAVEN
Practice Address - State:MI
Practice Address - Zip Code:49090-6743
Practice Address - Country:US
Practice Address - Phone:269-637-5271
Practice Address - Fax:269-639-2818
Is Sole Proprietor?:No
Enumeration Date:2005-09-27
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36100980207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1023138633OtherGROUP NPI NUMBER
IL31622992OtherBCBS
IL036-100980OtherSTATE LICENSE NUMBER
IL036100980Medicaid
IL036-100980OtherSTATE LICENSE NUMBER