Provider Demographics
NPI:1780661579
Name:NICHOLS, BRIAN GERARD (OD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:GERARD
Last Name:NICHOLS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:10 OAKLAND DR
Mailing Address - Street 2:
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23601-3623
Mailing Address - Country:US
Mailing Address - Phone:757-534-7908
Mailing Address - Fax:757-764-6970
Practice Address - Street 1:45 PINE RD.
Practice Address - Street 2:1ST MEDICAL GROUP
Practice Address - City:LANGLEY AFB
Practice Address - State:VA
Practice Address - Zip Code:23665-2080
Practice Address - Country:US
Practice Address - Phone:757-764-6975
Practice Address - Fax:757-764-6970
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2939152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist