Provider Demographics
NPI:1205827334
Name:NICHOLSON, BARNEY MATHEWS JR (MD)
Entity Type:Individual
Prefix:DR
First Name:BARNEY
Middle Name:MATHEWS
Last Name:NICHOLSON
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:10715 LONGFELLOW TRCE
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71106-9340
Mailing Address - Country:US
Mailing Address - Phone:601-559-9770
Mailing Address - Fax:
Practice Address - Street 1:510 E STONER AVE
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71101-4243
Practice Address - Country:US
Practice Address - Phone:318-990-4989
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-28
Last Update Date:2022-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG 74505208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
H45103Medicare UPIN