Provider Demographics
NPI:1467540674
Name:NICHOLAS, THOMAS MICHAEL (OD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:MICHAEL
Last Name:NICHOLAS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1204 W WILLOW RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:ENID
Mailing Address - State:OK
Mailing Address - Zip Code:73703-2531
Mailing Address - Country:US
Mailing Address - Phone:580-234-2333
Mailing Address - Fax:580-234-0820
Practice Address - Street 1:1204 W WILLOW RD
Practice Address - Street 2:SUITE A
Practice Address - City:ENID
Practice Address - State:OK
Practice Address - Zip Code:73703-2531
Practice Address - Country:US
Practice Address - Phone:580-234-2333
Practice Address - Fax:580-234-0820
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-11
Last Update Date:2014-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK848152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK848OtherSTATE LICENSE NUMER
OK848OtherSTATE LICENSE NUMER