Provider Demographics
NPI:1467404673
Name:NICHOLS, RICHARD T (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:T
Last Name:NICHOLS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:MR
Other - First Name:RICHARD
Other - Middle Name:T
Other - Last Name:NICHOLS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:2674 CALLE PERA
Mailing Address - Street 2:
Mailing Address - City:THOUSAND OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91360-6632
Mailing Address - Country:US
Mailing Address - Phone:805-493-2331
Mailing Address - Fax:
Practice Address - Street 1:2100 LYNN RD
Practice Address - Street 2:#250
Practice Address - City:THOUSAND OAKS
Practice Address - State:CA
Practice Address - Zip Code:91360
Practice Address - Country:US
Practice Address - Phone:805-493-2331
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-16
Last Update Date:2007-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG19630208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G196301Medicaid
CA00G196301Medicaid
A40707Medicare UPIN