Provider Demographics
NPI:1710923065
Name:NICHOLSON, DAVID W (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:W
Last Name:NICHOLSON
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 1:479 HEYWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:SPARTANBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29307
Mailing Address - Country:US
Mailing Address - Phone:864-583-6381
Mailing Address - Fax:864-583-6390
Practice Address - Street 1:479 HEYWOOD AVE
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29307
Practice Address - Country:US
Practice Address - Phone:864-583-6381
Practice Address - Fax:864-583-6390
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2007-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC5714207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCP00318197OtherRAILROAD MEDICARE INDIVID
SC057146Medicaid
SCCJ6730OtherRAILROAD MEDICARE GROUP
SCC60718Medicare UPIN