Provider Demographics
NPI:1013069939
Name:NICHOLS, ROBERT KENNETH JR (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:KENNETH
Last Name:NICHOLS
Suffix:JR
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 1:120 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PRATTVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:36067-3114
Mailing Address - Country:US
Mailing Address - Phone:334-361-0986
Mailing Address - Fax:334-361-1134
Practice Address - Street 1:120 E MAIN ST
Practice Address - Street 2:
Practice Address - City:PRATTVILLE
Practice Address - State:AL
Practice Address - Zip Code:36067-3114
Practice Address - Country:US
Practice Address - Phone:334-361-0986
Practice Address - Fax:334-361-1134
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-18
Last Update Date:2014-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL12055174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALC73810OtherUPNUMBER
ALC73810OtherUPNUMBER
AL000014632Medicare ID - Type UnspecifiedMEDICARE PROVIDER NO