Provider Demographics
NPI:1275577280
Name:NICHOLS, SCOTT RICHARD (MD)
Entity Type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:RICHARD
Last Name:NICHOLS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3801 CAMDEN RD # 22
Mailing Address - Street 2:
Mailing Address - City:PINE BLUFF
Mailing Address - State:AR
Mailing Address - Zip Code:71603-4612
Mailing Address - Country:US
Mailing Address - Phone:870-879-3517
Mailing Address - Fax:870-879-6049
Practice Address - Street 1:3801 CAMDEN RD # 22
Practice Address - Street 2:
Practice Address - City:PINE BLUFF
Practice Address - State:AR
Practice Address - Zip Code:71603-4612
Practice Address - Country:US
Practice Address - Phone:870-879-3517
Practice Address - Fax:870-879-6049
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-16
Last Update Date:2015-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC6461207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR110603001Medicaid
4535270OtherAETNA
AR13838000000OtherQUALCHOICE OF ARKANSAS
AR13838000000OtherQUALCHOICE OF ARKANSAS
D17022Medicare UPIN