Provider Demographics
NPI:1447237086
Name:NICHOLAS, NORMAN A (LDO)
Entity Type:Individual
Prefix:MR
First Name:NORMAN
Middle Name:A
Last Name:NICHOLAS
Suffix:
Gender:M
Credentials:LDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1311 W SPRING ST
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:GA
Mailing Address - Zip Code:30655-1758
Mailing Address - Country:US
Mailing Address - Phone:770-267-7824
Mailing Address - Fax:770-207-0072
Practice Address - Street 1:1311 W SPRING ST
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:GA
Practice Address - Zip Code:30655-1758
Practice Address - Country:US
Practice Address - Phone:770-267-7824
Practice Address - Fax:770-207-0072
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-26
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALDO000998156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA55594554SAMedicare ID - Type UnspecifiedMEDICARE/AETNA
GA0487240001Medicare ID - Type UnspecifiedMEDICARE/PALMETTO GBA