Provider Demographics
NPI:1689735144
Name:NICHOLSON, MARIO E (MD)
Entity Type:Individual
Prefix:DR
First Name:MARIO
Middle Name:E
Last Name:NICHOLSON
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:2101 EAST JEFFERSON STREET
Mailing Address - Street 2:PPQA MEDICARE COMPLIANCE UNITE 4 WEST KAISER PERMANENTE
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20852-4908
Mailing Address - Country:US
Mailing Address - Phone:301-816-6660
Mailing Address - Fax:301-816-6308
Practice Address - Street 1:6525 BELCREST ROAD
Practice Address - Street 2:SUITE 160
Practice Address - City:HYATTSVILLE
Practice Address - State:MD
Practice Address - Zip Code:20782-2016
Practice Address - Country:US
Practice Address - Phone:301-209-6155
Practice Address - Fax:301-209-6206
Is Sole Proprietor?:No
Enumeration Date:2006-12-12
Last Update Date:2023-02-16
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Provider Licenses
StateLicense IDTaxonomies
DCMD21652207R00000X
MDD41747207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD182511900Medicaid
016608K92Medicare ID - Type Unspecified