Provider Demographics
NPI:1497734461
Name:NICOLSON, STEPHEN EDWIN (MD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:EDWIN
Last Name:NICOLSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1313 21ST AVE S
Mailing Address - Street 2:VANDERBILT UNIVERSITY MEDICAL CENTER, 1103 OXFORD HOUSE
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37232-0001
Mailing Address - Country:US
Mailing Address - Phone:615-875-5838
Mailing Address - Fax:
Practice Address - Street 1:1313 21ST AVE S
Practice Address - Street 2:VANDERBILT UNIVERSITY MEDICAL CENTER, 1103 OXFORD HOUSE
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37232-0001
Practice Address - Country:US
Practice Address - Phone:615-875-5838
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-10
Last Update Date:2012-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0543332084P0800X
NY2438382084P0800X
TN485492084P0015X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0015XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychosomatic Medicine
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02896519Medicaid
MA2117096Medicaid
MA2117096Medicaid
MAA39823Medicare ID - Type Unspecified