Provider Demographics
NPI:1609965417
Name:NICHOLS, IVAN (MD)
Entity Type:Individual
Prefix:
First Name:IVAN
Middle Name:
Last Name:NICHOLS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:IVAN
Other - Middle Name:RAY
Other - Last Name:NICHOLS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:2501 E CHAPMAN AVE
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92869-3204
Mailing Address - Country:US
Mailing Address - Phone:714-633-1011
Mailing Address - Fax:714-633-4883
Practice Address - Street 1:2501 E CHAPMAN AVE
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92869-3204
Practice Address - Country:US
Practice Address - Phone:714-633-1011
Practice Address - Fax:714-633-4883
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2021-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG24810207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA42402Medicare UPIN
CAWG24810BMedicare ID - Type Unspecified