Provider Demographics
NPI:1164823142
Name:BEM, NICHOLAS E (OD)
Entity Type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:E
Last Name:BEM
Suffix:
Gender:M
Credentials:OD
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Other - Last Name:
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Mailing Address - Street 1:27TH SPECIAL OPERATIONS MEDICAL GROUP
Mailing Address - Street 2:224 W D.L. INGRAM AVENUE, BLDG. 1408
Mailing Address - City:CANNON AFB
Mailing Address - State:NM
Mailing Address - Zip Code:88103
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:27TH SPECIAL OPERATIONS MEDICAL GROUP
Practice Address - Street 2:224 W D.L. INGRAM AVENUE, BLDG. 1408
Practice Address - City:CANNON AFB
Practice Address - State:NM
Practice Address - Zip Code:88103
Practice Address - Country:US
Practice Address - Phone:575-904-3881
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-10
Last Update Date:2024-03-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
UT11106297-9934152W00000X
NC2376152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT11106297-9934OtherSTATE OF UTAH DEPARTMENT OF COMMERCE
NC2376OtherNC BOARD OF OPTOMETRY