Provider Demographics
NPI:1275721060
Name:NICHOLSON, JULIAN O (MD)
Entity Type:Individual
Prefix:DR
First Name:JULIAN
Middle Name:O
Last Name:NICHOLSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 587
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83303-0587
Mailing Address - Country:US
Mailing Address - Phone:208-814-7400
Mailing Address - Fax:208-814-7491
Practice Address - Street 1:730 N COLLEGE RD
Practice Address - Street 2:SUITE B
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-3382
Practice Address - Country:US
Practice Address - Phone:208-814-7350
Practice Address - Fax:208-732-8508
Is Sole Proprietor?:No
Enumeration Date:2007-10-05
Last Update Date:2015-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM3181207YS0123X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YS0123XAllopathic & Osteopathic PhysiciansOtolaryngologyFacial Plastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID003855700Medicaid
IDP00721165OtherMCRR
IDC36817OtherUPIN
ID1109491Medicare PIN