Provider Demographics
NPI:1336114891
Name:NICHOLS, ROGER D (MD)
Entity Type:Individual
Prefix:DR
First Name:ROGER
Middle Name:D
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 1:42 GARDEN CTR
Mailing Address - Street 2:
Mailing Address - City:BROOMFIELD
Mailing Address - State:CO
Mailing Address - Zip Code:80020-1730
Mailing Address - Country:US
Mailing Address - Phone:303-465-0401
Mailing Address - Fax:
Practice Address - Street 1:4747 ARAPAHOE AVE
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80303-1131
Practice Address - Country:US
Practice Address - Phone:303-415-7000
Practice Address - Fax:303-438-1351
Is Sole Proprietor?:No
Enumeration Date:2006-02-20
Last Update Date:2021-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO359932085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01359934Medicaid
COP00071179OtherBRI MEDICARE RAILROAD
COP00071179OtherBRI MEDICARE RAILROAD
COC99614Medicare PIN
COH7088Medicare ID - Type UnspecifiedMEDICAL IMAGING CENTER