Provider Demographics
NPI:1003001017
Name:NICHOLS, LAWRENCE MARTIN (MD)
Entity Type:Individual
Prefix:DR
First Name:LAWRENCE
Middle Name:MARTIN
Last Name:NICHOLS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:5471 LA PALMA AVE
Mailing Address - Street 2:STE. 202
Mailing Address - City:LA PALMA
Mailing Address - State:CA
Mailing Address - Zip Code:90623-1745
Mailing Address - Country:US
Mailing Address - Phone:714-522-2041
Mailing Address - Fax:714-522-8246
Practice Address - Street 1:5471 LA PALMA AVE
Practice Address - Street 2:STE. 202
Practice Address - City:LA PALMA
Practice Address - State:CA
Practice Address - Zip Code:90623-1745
Practice Address - Country:US
Practice Address - Phone:714-522-2041
Practice Address - Fax:714-522-8246
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-12
Last Update Date:2010-09-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA23444207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAD1705ZMedicare PIN