Provider Demographics
NPI:1790753747
Name:NICOL, THERESA (MD)
Entity Type:Individual
Prefix:DR
First Name:THERESA
Middle Name:
Last Name:NICOL
Suffix:
Gender:F
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:PO BOX 64546
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21264-4546
Mailing Address - Country:US
Mailing Address - Phone:240-364-2550
Mailing Address - Fax:240-364-9020
Practice Address - Street 1:4801 TELSA DR
Practice Address - Street 2:SUITE G
Practice Address - City:BOWIE
Practice Address - State:MD
Practice Address - Zip Code:20715-4320
Practice Address - Country:US
Practice Address - Phone:410-987-8001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-08
Last Update Date:2007-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0047638207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology