Provider Demographics
NPI:1891780227
Name:NICHOLS, MARK EDWARD (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:EDWARD
Last Name:NICHOLS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:605 S CONROE MEDICAL DR
Mailing Address - Street 2:
Mailing Address - City:CONROE
Mailing Address - State:TX
Mailing Address - Zip Code:77304-4722
Mailing Address - Country:US
Mailing Address - Phone:936-539-4004
Mailing Address - Fax:936-539-3635
Practice Address - Street 1:605 S CONROE MEDICAL DR
Practice Address - Street 2:
Practice Address - City:CONROE
Practice Address - State:TX
Practice Address - Zip Code:77304-4722
Practice Address - Country:US
Practice Address - Phone:936-539-4004
Practice Address - Fax:936-539-3635
Is Sole Proprietor?:No
Enumeration Date:2005-09-12
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXL0457207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1560377-03Medicaid
TXBN6947761OtherDEA
00897YMedicare PIN