Provider Demographics
NPI:1942486873
Name:NICHOLAS, MICHAEL JOHN (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:JOHN
Last Name:NICHOLAS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:100 SOUTH ASHLEY DRIVE
Mailing Address - Street 2:SUITE 1500
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33602-5318
Mailing Address - Country:US
Mailing Address - Phone:813-899-6220
Mailing Address - Fax:813-985-8006
Practice Address - Street 1:100 SOUTH ASHLEY DRIVE
Practice Address - Street 2:SUITE 1500
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33602-5318
Practice Address - Country:US
Practice Address - Phone:813-899-6220
Practice Address - Fax:813-985-8006
Is Sole Proprietor?:No
Enumeration Date:2008-01-10
Last Update Date:2015-03-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MDD00684292085B0100X
PAMD4395082085R0202X
FLME1172742085B0100X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody Imaging
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL010165200Medicaid
FL010165200Medicaid