Provider Demographics
NPI:1497746630
Name:NICHOLS, JAMES ROBERT (MD)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:ROBERT
Last Name:NICHOLS
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 1:13838 S 46TH PL
Mailing Address - Street 2:STE 320
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85044-7804
Mailing Address - Country:US
Mailing Address - Phone:480-759-5151
Mailing Address - Fax:480-940-8649
Practice Address - Street 1:13838 S 46TH PL
Practice Address - Street 2:STE 320
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85044-7804
Practice Address - Country:US
Practice Address - Phone:480-759-5151
Practice Address - Fax:480-940-8649
Is Sole Proprietor?:No
Enumeration Date:2005-11-04
Last Update Date:2008-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ29489207P00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ586018Medicaid
3981220OtherEVERCARE GRP
AZAW1436OtherHEALTHNET GRP
AZAZ0728670OtherBLUE CROSS BLUE SHIELD GR
Z117071Medicare PIN
AZAZ0728670OtherBLUE CROSS BLUE SHIELD GR
3981220OtherEVERCARE GRP