Provider Demographics
NPI:1750611794
Name:NICKERSON, WARREN RUSSELL (MD)
Entity type:Individual
Prefix:
First Name:WARREN
Middle Name:RUSSELL
Last Name:NICKERSON
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 1:24 HANNAH CIRCLE
Mailing Address - Street 2:
Mailing Address - City:COTUIT
Mailing Address - State:MA
Mailing Address - Zip Code:02635
Mailing Address - Country:US
Mailing Address - Phone:508-428-2085
Mailing Address - Fax:
Practice Address - Street 1:1 PEARL ST
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301-2864
Practice Address - Country:US
Practice Address - Phone:508-584-4107
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-01-13
Last Update Date:2014-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA29149208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice