Provider Demographics
NPI:1376541490
Name:NICHOLSON, BRIAN EMISON (MD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:EMISON
Last Name:NICHOLSON
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 1:3420 22ND PL
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79410-1314
Mailing Address - Country:US
Mailing Address - Phone:806-725-5844
Mailing Address - Fax:806-723-6532
Practice Address - Street 1:3612 23RD ST
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79410-1326
Practice Address - Country:US
Practice Address - Phone:806-793-8787
Practice Address - Fax:806-793-0150
Is Sole Proprietor?:No
Enumeration Date:2005-07-12
Last Update Date:2014-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL9397208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX178560201Medicaid
TX178560201Medicaid
TXI22308Medicare UPIN