Provider Demographics
NPI:1578502076
Name:NICHOLS, JAMES WALTON (MD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:WALTON
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 1:9855 NORRIS FERRY RD
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71106
Mailing Address - Country:US
Mailing Address - Phone:318-798-3391
Mailing Address - Fax:
Practice Address - Street 1:ONE ST MARY PLACE
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71101
Practice Address - Country:US
Practice Address - Phone:318-681-4500
Practice Address - Fax:318-681-4177
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA14178R207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1113492Medicaid
G99995Medicare UPIN
LA1113492Medicaid