Provider Demographics
NPI:1104834142
Name:NICHOLS, PETER W (MD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:W
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 512565
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90051-0565
Mailing Address - Country:US
Mailing Address - Phone:323-442-2582
Mailing Address - Fax:323-442-2588
Practice Address - Street 1:1441 EASTLAKE AVE
Practice Address - Street 2:SUITE 2424
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90089-0112
Practice Address - Country:US
Practice Address - Phone:323-442-2582
Practice Address - Fax:323-442-2588
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2008-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG38456207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1952325565OtherGROUP NPI
CA00G384560OtherBLUE SHIELD
CA00G384560Medicaid
CA00G384560Medicaid
CAHW7801AMedicare PIN
CA00G384560OtherBLUE SHIELD
CAHW7801BMedicare PIN
CAW7801BMedicare PIN
CAWG38456EMedicare PIN
CAWG38456BMedicare PIN