Provider Demographics
NPI:1659361699
Name:NICHOLAS, THOMAS D (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:D
Last Name:NICHOLAS
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 1:111 W HIGH ST
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47872-1735
Mailing Address - Country:US
Mailing Address - Phone:765-569-2057
Mailing Address - Fax:765-569-2340
Practice Address - Street 1:111 W HIGH ST
Practice Address - Street 2:
Practice Address - City:ROCKVILLE
Practice Address - State:IN
Practice Address - Zip Code:47872-1735
Practice Address - Country:US
Practice Address - Phone:765-569-2057
Practice Address - Fax:765-569-2340
Is Sole Proprietor?:No
Enumeration Date:2005-10-21
Last Update Date:2008-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01025421A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
INC25412Medicare UPIN
IN620590BMedicare ID - Type Unspecified