Provider Demographics
NPI:1295766038
Name:NICHOLS, CODY A (MD)
Entity type:Individual
Prefix:
First Name:CODY
Middle Name:A
Last Name:NICHOLS
Suffix:
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 1:1305 WONDER WORLD DR STE 306
Mailing Address - Street 2:
Mailing Address - City:SAN MARCOS
Mailing Address - State:TX
Mailing Address - Zip Code:78666-7542
Mailing Address - Country:US
Mailing Address - Phone:512-396-1000
Mailing Address - Fax:512-353-2554
Practice Address - Street 1:1305 WONDER WORLD DR STE 306
Practice Address - Street 2:
Practice Address - City:SAN MARCOS
Practice Address - State:TX
Practice Address - Zip Code:78666-7542
Practice Address - Country:US
Practice Address - Phone:512-396-1000
Practice Address - Fax:512-353-2554
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2007-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM1981207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8J3213Medicare PIN
TXI21026Medicare UPIN