Provider Demographics
NPI:1124083100
Name:NICHOLAS, CHARLES CHRISTOPHER (DPM)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:CHRISTOPHER
Last Name:NICHOLAS
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:3720 HOLLAND RD
Mailing Address - Street 2:STE 100
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23452-2859
Mailing Address - Country:US
Mailing Address - Phone:757-498-0202
Mailing Address - Fax:757-498-7936
Practice Address - Street 1:3720 HOLLAND RD
Practice Address - Street 2:STE 100
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23452-2859
Practice Address - Country:US
Practice Address - Phone:757-498-0202
Practice Address - Fax:757-498-7936
Is Sole Proprietor?:No
Enumeration Date:2006-04-20
Last Update Date:2018-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0103300941213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010210241Medicaid
VAP00324323OtherRR MEDICARE
VA2138899OtherMDIPA
VA5180770001OtherDMERC
VA5180770002OtherDMERC
10007473OtherOPTIMA HEALTH
VA196666OtherANTHEM BLUE CROSS BLUE SH
VA009929N03Medicare PIN
VA2138899OtherMDIPA