Provider Demographics
NPI:1518942333
Name:NICHOLS, ROBERT CARROLL (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:CARROLL
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 1:720 PLEASANTON RD
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78214-1306
Mailing Address - Country:US
Mailing Address - Phone:210-921-3800
Mailing Address - Fax:
Practice Address - Street 1:7219 CULEBRA RD
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78251
Practice Address - Country:US
Practice Address - Phone:210-509-2603
Practice Address - Fax:210-334-2851
Is Sole Proprietor?:No
Enumeration Date:2005-12-14
Last Update Date:2018-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL8456207Q00000X
FLME112824207Q00000X
NC2009-00826207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX415887YKQQMedicare PIN