Provider Demographics
NPI:1407998420
Name:NICHOLS, ALLEN BRYANT (MD)
Entity Type:Individual
Prefix:DR
First Name:ALLEN
Middle Name:BRYANT
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 1:12720 MCMANUS BLVD
Mailing Address - Street 2:#201
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23602-4414
Mailing Address - Country:US
Mailing Address - Phone:757-875-5332
Mailing Address - Fax:757-874-1545
Practice Address - Street 1:12720 MCMANUS BLVD
Practice Address - Street 2:SUITE 201
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23602-4414
Practice Address - Country:US
Practice Address - Phone:757-875-5332
Practice Address - Fax:757-874-1545
Is Sole Proprietor?:No
Enumeration Date:2007-02-13
Last Update Date:2011-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101036628207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010130409Medicaid
VA00W259P01Medicare ID - Type Unspecified
VA010130409Medicaid