Provider Demographics
NPI:1093752073
Name:NICHOLS, TIMOTHY D (MD)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:D
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:PO BOX 797885
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75379-7885
Mailing Address - Country:US
Mailing Address - Phone:940-626-0059
Mailing Address - Fax:940-627-2289
Practice Address - Street 1:12606 GREENVILLE AVE
Practice Address - Street 2:SUITE 160
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75243-1921
Practice Address - Country:US
Practice Address - Phone:469-364-7880
Practice Address - Fax:469-364-7895
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2021-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ1744174400000X, 2085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX126533203Medicaid
TX920003991OtherRAILROAD MEDICARE
TX920003991OtherRAILROAD MEDICARE
TXOOT83FMedicare ID - Type Unspecified