Provider Demographics
NPI:1700840840
Name:NICHOLS, BRIAN KEITH (OD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:KEITH
Last Name:NICHOLS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2001 W FERGUSON RD
Mailing Address - Street 2:SUITE 2020
Mailing Address - City:MT PLEASANT
Mailing Address - State:TX
Mailing Address - Zip Code:75455-2925
Mailing Address - Country:US
Mailing Address - Phone:903-572-1991
Mailing Address - Fax:903-572-4718
Practice Address - Street 1:2001 W FERGUSON RD
Practice Address - Street 2:SUITE 2020
Practice Address - City:MT PLEASANT
Practice Address - State:TX
Practice Address - Zip Code:75455-2925
Practice Address - Country:US
Practice Address - Phone:903-572-1991
Practice Address - Fax:903-572-4718
Is Sole Proprietor?:No
Enumeration Date:2006-04-14
Last Update Date:2009-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX5439TG152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX199333901Medicaid
TX00Z864Medicare PIN
TXU67320Medicare UPIN
TX6195690001Medicare NSC