Provider Demographics
NPI:1487677290
Name:WADSWORTH, NICOLE (DO)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:WADSWORTH
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 WARWICK LN
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:OH
Mailing Address - Zip Code:45701-3368
Mailing Address - Country:US
Mailing Address - Phone:740-707-4598
Mailing Address - Fax:
Practice Address - Street 1:7123 PEARL RD
Practice Address - Street 2:
Practice Address - City:MIDDLEBURG HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44130-4975
Practice Address - Country:US
Practice Address - Phone:440-842-7990
Practice Address - Fax:440-842-8835
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2016-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34.007038207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH942460636917OtherCARESOURCE
OHP00285501OtherMEDICARE RR-GA
OH2184523Medicaid
OH2184523Medicaid
OH942460636917OtherCARESOURCE