Provider Demographics
NPI:1780643742
Name:NICHOLAS, STEPHEN PETER (MD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:PETER
Last Name:NICHOLAS
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 1:1505 53RD AVE E
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34203-4249
Mailing Address - Country:US
Mailing Address - Phone:941-357-7950
Mailing Address - Fax:941-840-1003
Practice Address - Street 1:1505 53RD AVE E
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34203-4249
Practice Address - Country:US
Practice Address - Phone:941-357-7950
Practice Address - Fax:941-840-1003
Is Sole Proprietor?:No
Enumeration Date:2006-03-20
Last Update Date:2021-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME140408207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO202193207Medicaid
MOA09727Medicare UPIN
MO103514616Medicare PIN