Provider Demographics
NPI:1013112143
Name:NICHOLS, PETER WARNER JR (MD)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:WARNER
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 1:904 W DIVERSEY PKWY APT 2W
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614-1468
Mailing Address - Country:US
Mailing Address - Phone:626-253-0786
Mailing Address - Fax:
Practice Address - Street 1:1400 E IRVING PARK RD
Practice Address - Street 2:
Practice Address - City:STREAMWOOD
Practice Address - State:IL
Practice Address - Zip Code:60107-3201
Practice Address - Country:US
Practice Address - Phone:630-837-9000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-19
Last Update Date:2011-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.1185482084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry