Provider Demographics
NPI:1942241633
Name:NICHOLSON, MICHAEL (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:NICHOLSON
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 1:6341 DEER CROSS DR
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48348-2830
Mailing Address - Country:US
Mailing Address - Phone:248-620-6076
Mailing Address - Fax:
Practice Address - Street 1:1428 S LAPEER RD
Practice Address - Street 2:
Practice Address - City:LAKE ORION
Practice Address - State:MI
Practice Address - Zip Code:48360-1437
Practice Address - Country:US
Practice Address - Phone:248-693-0543
Practice Address - Fax:248-693-3683
Is Sole Proprietor?:No
Enumeration Date:2006-06-10
Last Update Date:2024-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301068186207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4705424Medicaid
MI4705424Medicaid
MI4705424Medicaid