Provider Demographics
NPI:1457469801
Name:NICHOLS, JOEL LAWRENCE (DPM)
Entity Type:Individual
Prefix:DR
First Name:JOEL
Middle Name:LAWRENCE
Last Name:NICHOLS
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1444 MASSACHUSETTS AVE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:TROY
Mailing Address - State:NY
Mailing Address - Zip Code:12180-1600
Mailing Address - Country:US
Mailing Address - Phone:518-266-1205
Mailing Address - Fax:518-266-1270
Practice Address - Street 1:1444 MASSACHUSETTS AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:TROY
Practice Address - State:NY
Practice Address - Zip Code:12180-1600
Practice Address - Country:US
Practice Address - Phone:518-266-1205
Practice Address - Fax:518-266-1270
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-27
Last Update Date:2011-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN005539-1213E00000X
VT056-0000170213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY000493808004OtherBSNENY
NYP00237591OtherRRMC
NY02133746Medicaid
NY10031220OtherCDPHP
NY699362OtherMVP
NYDD6373Medicare ID - Type Unspecified
NY000493808004OtherBSNENY
NY699362OtherMVP