Provider Demographics
NPI:1629090022
Name:NICHOLLS, TIM (MD)
Entity Type:Individual
Prefix:
First Name:TIM
Middle Name:
Last Name:NICHOLLS
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:PO BOX 254947
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95865-4947
Mailing Address - Country:US
Mailing Address - Phone:916-854-6975
Mailing Address - Fax:916-854-6864
Practice Address - Street 1:3700 CALIFORNIA ST
Practice Address - Street 2:DEPARTMENT OF PEDIATRICS
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94118-1618
Practice Address - Country:US
Practice Address - Phone:415-923-3291
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2007-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA73793208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAH90549Medicare UPIN
CA00A737931Medicare ID - Type Unspecified