Provider Demographics
NPI:1619952264
Name:NICHOLS, CONSTANCE G (MD)
Entity Type:Individual
Prefix:
First Name:CONSTANCE
Middle Name:G
Last Name:NICHOLS
Suffix:
Gender:F
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:PO BOX 415348
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-5348
Mailing Address - Country:US
Mailing Address - Phone:800-225-8885
Mailing Address - Fax:508-334-1977
Practice Address - Street 1:55 LAKE AVE N
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01655
Practice Address - Country:US
Practice Address - Phone:508-421-1400
Practice Address - Fax:508-421-1490
Is Sole Proprietor?:No
Enumeration Date:2005-12-07
Last Update Date:2018-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA55749207P00000X, 2083C0008X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No2083C0008XAllopathic & Osteopathic PhysiciansPreventive MedicineClinical Informatics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110042960AMedicaid
MAJ0558101Medicare PIN
MA3006492Medicaid