Provider Demographics
NPI:1700223674
Name:NICHOLLS, FRED HERBERT (MD)
Entity Type:Individual
Prefix:DR
First Name:FRED
Middle Name:HERBERT
Last Name:NICHOLLS
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 1:500 PARNASSUS AVE
Mailing Address - Street 2:MU 320
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94143-2203
Mailing Address - Country:US
Mailing Address - Phone:415-476-6043
Mailing Address - Fax:
Practice Address - Street 1:500 PARNASSUS AVE
Practice Address - Street 2:MU 320
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94143-2203
Practice Address - Country:US
Practice Address - Phone:415-476-6043
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-31
Last Update Date:2013-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA125674390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program