Provider Demographics
NPI:1952476053
Name:NICHOLS, EDWARD ATKINSON (MD)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:ATKINSON
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 1:210 W 139TH ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10030-2109
Mailing Address - Country:US
Mailing Address - Phone:212-234-2121
Mailing Address - Fax:212-234-1759
Practice Address - Street 1:210 W 139TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10030-2109
Practice Address - Country:US
Practice Address - Phone:212-234-2121
Practice Address - Fax:212-234-1759
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-22
Last Update Date:2012-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY093296-1208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00151804Medicaid
NY676432OtherBLUE CROSS BLU SHIELD
NY00151804Medicaid