Provider Demographics
NPI:1134180631
Name:NICHTING, THEODORE WILLIAM (OD)
Entity type:Individual
Prefix:
First Name:THEODORE
Middle Name:WILLIAM
Last Name:NICHTING
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:260 EAST MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:OH
Mailing Address - Zip Code:45640
Mailing Address - Country:US
Mailing Address - Phone:740-286-5022
Mailing Address - Fax:740-286-7000
Practice Address - Street 1:260 EAST MAIN STREET
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:OH
Practice Address - Zip Code:45640
Practice Address - Country:US
Practice Address - Phone:740-286-5022
Practice Address - Fax:740-286-7000
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2918152W00000X
OHT578152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0214735Medicaid
T46661Medicare UPIN
OHNI0400922Medicare ID - Type Unspecified