Provider Demographics
NPI:1639208903
Name:JOHN C. NICHOLSON, MD
Entity Type:Organization
Organization Name:JOHN C. NICHOLSON, MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:C
Authorized Official - Last Name:NICHOLSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:802-524-4554
Mailing Address - Street 1:PO BOX 1363
Mailing Address - Street 2:
Mailing Address - City:WILLISTON
Mailing Address - State:VT
Mailing Address - Zip Code:05495-1363
Mailing Address - Country:US
Mailing Address - Phone:802-524-7100
Mailing Address - Fax:802-524-7021
Practice Address - Street 1:2 CREST RD
Practice Address - Street 2:
Practice Address - City:SAINT ALBANS
Practice Address - State:VT
Practice Address - Zip Code:05478-9753
Practice Address - Country:US
Practice Address - Phone:802-524-4554
Practice Address - Fax:802-524-3216
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0420010190207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT0VN2606Medicaid
E58919Medicare UPIN
VN2606Medicare ID - Type Unspecified