Provider Demographics
NPI:1346462983
Name:PAUL G. NICHOLAS III, D.O., P.A.
Entity Type:Organization
Organization Name:PAUL G. NICHOLAS III, D.O., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:NICHOLAS
Authorized Official - Suffix:III
Authorized Official - Credentials:DO
Authorized Official - Phone:856-769-0900
Mailing Address - Street 1:PO BOX 304
Mailing Address - Street 2:24 EAST AVE
Mailing Address - City:WOODSTOWN
Mailing Address - State:NJ
Mailing Address - Zip Code:08098-0304
Mailing Address - Country:US
Mailing Address - Phone:856-769-0900
Mailing Address - Fax:856-769-2639
Practice Address - Street 1:24 EAST AVE
Practice Address - Street 2:
Practice Address - City:WOODSTOWN
Practice Address - State:NJ
Practice Address - Zip Code:08098-1409
Practice Address - Country:US
Practice Address - Phone:856-769-0900
Practice Address - Fax:856-769-2639
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMB040789207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ126067Medicare ID - Type Unspecified
NJC53291Medicare UPIN