Provider Demographics
NPI:1215180328
Name:NICHOLSON, DONTESE JAMINE (MD)
Entity Type:Individual
Prefix:DR
First Name:DONTESE
Middle Name:JAMINE
Last Name:NICHOLSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:11350 MCCORMICK RD
Mailing Address - Street 2:EXECUTIVE PLAZA I, SUITE 501
Mailing Address - City:HUNT VALLEY
Mailing Address - State:MD
Mailing Address - Zip Code:21031-1002
Mailing Address - Country:US
Mailing Address - Phone:410-682-2823
Mailing Address - Fax:410-682-9551
Practice Address - Street 1:6820 HOSPITAL DR
Practice Address - Street 2:STE 302
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21237-4352
Practice Address - Country:US
Practice Address - Phone:410-682-2823
Practice Address - Fax:410-682-9551
Is Sole Proprietor?:No
Enumeration Date:2008-11-03
Last Update Date:2021-06-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MDD0074632208VP0014X, 207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD249081ZAZQMedicare PIN
DC249056ZBOUMedicare PIN