Provider Demographics
NPI:1154327617
Name:NICHOLSON, WILLIAM D IV (MD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:D
Last Name:NICHOLSON
Suffix:IV
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:NICK
Other - Middle Name:
Other - Last Name:NICHOLSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:5000 LEGACY DR.
Mailing Address - Street 2:SUITE 200
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75024-3373
Mailing Address - Country:US
Mailing Address - Phone:972-494-3100
Mailing Address - Fax:972-608-0005
Practice Address - Street 1:8080 INDEPENDENCE PKWY
Practice Address - Street 2:STE 115
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75025-4000
Practice Address - Country:US
Practice Address - Phone:972-494-3100
Practice Address - Fax:972-608-0005
Is Sole Proprietor?:No
Enumeration Date:2005-06-21
Last Update Date:2020-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL1953208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXH37882Medicare UPIN
TX144085101Medicaid
TX8F9115Medicare PIN