Provider Demographics
NPI:1013091941
Name:NICHOLSON, TIMOTHY
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:
Last Name:NICHOLSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:711 TROY SCHENECTADY RD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:LATHAM
Mailing Address - State:NY
Mailing Address - Zip Code:12110-2442
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1184 STATE ROUTE 50
Practice Address - Street 2:
Practice Address - City:BURNT HILLS
Practice Address - State:NY
Practice Address - Zip Code:12019-1923
Practice Address - Country:US
Practice Address - Phone:518-384-1281
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2013-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY217445207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02349659Medicaid
NY02349659Medicaid
NYDD2078Medicare PIN