Provider Demographics
NPI:1356301352
Name:NICHOLS, MICHAEL L (OD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:L
Last Name:NICHOLS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 KEENE ST
Mailing Address - Street 2:SUITE 103
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65201-8104
Mailing Address - Country:US
Mailing Address - Phone:573-874-2030
Mailing Address - Fax:573-449-0253
Practice Address - Street 1:500 KEENE ST
Practice Address - Street 2:SUITE 103
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65201-8104
Practice Address - Country:US
Practice Address - Phone:573-874-2030
Practice Address - Fax:573-449-0253
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2007-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOT02342152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO0270770001OtherNORIDIAN-DMERC
MO108175OtherBC/BS
MO108175OtherBC/BS