Provider Demographics
NPI:1659365161
Name:NICHOLS, RICHARD D (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:D
Last Name:NICHOLS
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 1725
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33802-1725
Mailing Address - Country:US
Mailing Address - Phone:863-683-5454
Mailing Address - Fax:863-683-4652
Practice Address - Street 1:515 E GARDEN ST
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33805-4615
Practice Address - Country:US
Practice Address - Phone:863-683-5454
Practice Address - Fax:863-683-4652
Is Sole Proprietor?:No
Enumeration Date:2005-09-12
Last Update Date:2012-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME88932174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL37724OtherBCBS
292845OtherAVMED
4036259OtherAETNA
210792OtherAMERIGROUP
239523OtherWELLCARE
FL38675ZMedicare ID - Type UnspecifiedGROUP
FLA77321Medicare UPIN
FL37724ZMedicare ID - Type UnspecifiedINDIVIDUAL