Provider Demographics
NPI:1225006901
Name:NICHOLSON, PETER J (MD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:J
Last Name:NICHOLSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 788
Mailing Address - Street 2:
Mailing Address - City:JAMESTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:14702-0788
Mailing Address - Country:US
Mailing Address - Phone:716-664-9731
Mailing Address - Fax:716-664-9160
Practice Address - Street 1:207 FOOTE AVE
Practice Address - Street 2:
Practice Address - City:JAMESTOWN
Practice Address - State:NY
Practice Address - Zip Code:14701-7077
Practice Address - Country:US
Practice Address - Phone:716-664-9731
Practice Address - Fax:716-664-9160
Is Sole Proprietor?:No
Enumeration Date:2006-03-09
Last Update Date:2018-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY176670-12085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02391995Medicaid
NYRB1431Medicare PIN
NY02391995Medicaid
NYRB1252Medicare PIN