Provider Demographics
NPI:1821189051
Name:NICHOLLS, ERIC OWEN (OD)
Entity Type:Individual
Prefix:DR
First Name:ERIC
Middle Name:OWEN
Last Name:NICHOLLS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35298 N SHERIDAN DR
Mailing Address - Street 2:
Mailing Address - City:INGLESIDE
Mailing Address - State:IL
Mailing Address - Zip Code:60041-8760
Mailing Address - Country:US
Mailing Address - Phone:847-858-6748
Mailing Address - Fax:
Practice Address - Street 1:3801 RUNNING BROOK FARM BLVD
Practice Address - Street 2:
Practice Address - City:JOHNSBURG
Practice Address - State:IL
Practice Address - Zip Code:60051-5425
Practice Address - Country:US
Practice Address - Phone:815-385-9224
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2016-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL46009345152W00000X, 152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILU90067Medicare UPIN