Provider Demographics
NPI:1629418587
Name:NICHOLSON, SUSAN (MD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:NICHOLSON
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 1:123 SANDY RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08559-1513
Mailing Address - Country:US
Mailing Address - Phone:609-647-7088
Mailing Address - Fax:
Practice Address - Street 1:1300 YORK AVE
Practice Address - Street 2:LC-423
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10065-4805
Practice Address - Country:US
Practice Address - Phone:609-647-7088
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-25
Last Update Date:2013-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY197494207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease