Provider Demographics
NPI:1376981175
Name:NICHOLLS, EDWARD R (OD)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:R
Last Name:NICHOLLS
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 1:323 W STATE RD STE A
Mailing Address - Street 2:
Mailing Address - City:AMERICAN FORK
Mailing Address - State:UT
Mailing Address - Zip Code:84003-5600
Mailing Address - Country:US
Mailing Address - Phone:801-763-9898
Mailing Address - Fax:801-763-7217
Practice Address - Street 1:323 W STATE RD STE A
Practice Address - Street 2:
Practice Address - City:AMERICAN FORK
Practice Address - State:UT
Practice Address - Zip Code:84003-5600
Practice Address - Country:US
Practice Address - Phone:801-763-9898
Practice Address - Fax:801-763-7217
Is Sole Proprietor?:No
Enumeration Date:2013-06-13
Last Update Date:2022-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8746430-9934152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist