Provider Demographics
NPI:1679634562
Name:NICHOLS, ROBERT L (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:L
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 1558
Mailing Address - Street 2:
Mailing Address - City:SANTA TERESA
Mailing Address - State:NM
Mailing Address - Zip Code:88008
Mailing Address - Country:US
Mailing Address - Phone:505-589-4000
Mailing Address - Fax:505-589-7225
Practice Address - Street 1:1300 COUNTRY CLUB ROAD
Practice Address - Street 2:
Practice Address - City:SANTA TERESA
Practice Address - State:NM
Practice Address - Zip Code:88008
Practice Address - Country:US
Practice Address - Phone:505-589-4000
Practice Address - Fax:505-589-7225
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM94-344207Q00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Not Answered208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
F93620Medicare UPIN