Provider Demographics
NPI:1679910574
Name:NICHOLS, ROBERT HENDERSON (DO)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:HENDERSON
Last Name:NICHOLS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1940 BERKELEY PL
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76110-1209
Mailing Address - Country:US
Mailing Address - Phone:817-307-9633
Mailing Address - Fax:
Practice Address - Street 1:6225 N STATE HIGHWAY 161 STE 200
Practice Address - Street 2:
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75038-2241
Practice Address - Country:US
Practice Address - Phone:214-687-0001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-31
Last Update Date:2018-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXBP10047100207L00000X
TXR3389207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology