Provider Demographics
NPI:1144227836
Name:NICHOLSON, BRADLEY WILLIAM (MD)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:WILLIAM
Last Name:NICHOLSON
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 1019
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:VA
Mailing Address - Zip Code:24171-1019
Mailing Address - Country:US
Mailing Address - Phone:276-694-4466
Mailing Address - Fax:276-694-2909
Practice Address - Street 1:18877 JEB STUART HWY
Practice Address - Street 2:
Practice Address - City:STUART
Practice Address - State:VA
Practice Address - Zip Code:24171
Practice Address - Country:US
Practice Address - Phone:276-694-4466
Practice Address - Fax:276-694-2909
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101030962208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAB59678Medicare UPIN
VA001235P01Medicare ID - Type Unspecified