Provider Demographics
NPI:1679553499
Name:NICHOLAS, DIANNE (MD)
Entity Type:Individual
Prefix:DR
First Name:DIANNE
Middle Name:
Last Name:NICHOLAS
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:PO BOX 14231
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77221-4231
Mailing Address - Country:US
Mailing Address - Phone:713-440-0602
Mailing Address - Fax:713-944-8903
Practice Address - Street 1:5160 TIMBER CREEK DR
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77017-5968
Practice Address - Country:US
Practice Address - Phone:713-440-0602
Practice Address - Fax:713-944-8903
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-18
Last Update Date:2009-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ2238207P00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXF48495Medicare UPIN