Provider Demographics
NPI:1982696837
Name:NUCKOLS, DOUGLAS A (MD)
Entity type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:A
Last Name:NUCKOLS
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 1:10021 DUPONT CIRCLE CT
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-1604
Mailing Address - Country:US
Mailing Address - Phone:260-426-8117
Mailing Address - Fax:260-420-0817
Practice Address - Street 1:10021 DUPONT CIRCLE CT
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825-1604
Practice Address - Country:US
Practice Address - Phone:260-426-8117
Practice Address - Fax:260-420-0817
Is Sole Proprietor?:No
Enumeration Date:2005-08-17
Last Update Date:2009-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01052220A207Y00000X
OH35-07-8501207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200262190Medicaid
OH2207543Medicaid
IN040014894Medicare PIN
IN047930JMedicare PIN
INH12326Medicare UPIN
IN200262190Medicaid