Provider Demographics
NPI:1003842048
Name:NICHOLS, JAMES T (MD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:T
Last Name:NICHOLS
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 1:1315 GARDEN ST
Mailing Address - Street 2:
Mailing Address - City:TITUSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32796-3312
Mailing Address - Country:US
Mailing Address - Phone:321-268-0128
Mailing Address - Fax:321-268-0668
Practice Address - Street 1:1315 GARDEN ST
Practice Address - Street 2:
Practice Address - City:TITUSVILLE
Practice Address - State:FL
Practice Address - Zip Code:32796-3312
Practice Address - Country:US
Practice Address - Phone:321-268-0128
Practice Address - Fax:321-268-0668
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME30371207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL05396OtherBLUE SHIELD
FLD51271Medicare UPIN
FL05396OtherBLUE SHIELD