Provider Demographics
NPI:1891781803
Name:NICHOLS, GARY A (MD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:A
Last Name:NICHOLS
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 1:3 E BENJAMIN DR
Mailing Address - Street 2:
Mailing Address - City:NEW MARTINSVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:26155-2705
Mailing Address - Country:US
Mailing Address - Phone:304-455-8080
Mailing Address - Fax:304-455-8141
Practice Address - Street 1:3 E BENJAMIN DR
Practice Address - Street 2:
Practice Address - City:NEW MARTINSVILLE
Practice Address - State:WV
Practice Address - Zip Code:26155-2705
Practice Address - Country:US
Practice Address - Phone:304-455-8080
Practice Address - Fax:304-455-8141
Is Sole Proprietor?:No
Enumeration Date:2005-09-26
Last Update Date:2020-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV21642207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810000963Medicaid
WV3810000963Medicaid
NI7327161Medicare ID - Type Unspecified