Provider Demographics
NPI:1760536478
Name:NICHOLSON, RICHARD EARL (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:EARL
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 1:3475 W LINE ST
Mailing Address - Street 2:
Mailing Address - City:BISHOP
Mailing Address - State:CA
Mailing Address - Zip Code:93514-2155
Mailing Address - Country:US
Mailing Address - Phone:760-937-7579
Mailing Address - Fax:
Practice Address - Street 1:52 N TU SU LN
Practice Address - Street 2:
Practice Address - City:BISHOP
Practice Address - State:CA
Practice Address - Zip Code:93514-8058
Practice Address - Country:US
Practice Address - Phone:760-873-8461
Practice Address - Fax:760-873-3530
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG070442207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAF32550Medicare UPIN
CA00G704421Medicare ID - Type UnspecifiedPPIN