Provider Demographics
NPI:1437140886
Name:NICHOLLS, EUGENE W (OD)
Entity Type:Individual
Prefix:MR
First Name:EUGENE
Middle Name:W
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 1:151 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36301-1625
Mailing Address - Country:US
Mailing Address - Phone:334-793-2633
Mailing Address - Fax:334-794-1626
Practice Address - Street 1:151 W MAIN ST
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36301-1625
Practice Address - Country:US
Practice Address - Phone:334-793-2633
Practice Address - Fax:334-794-1626
Is Sole Proprietor?:No
Enumeration Date:2005-11-03
Last Update Date:2008-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALS382TA204152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALT69011Medicare UPIN