Provider Demographics
NPI:1356387484
Name:NICHOLAS, WILLIAM JOHN (MD)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:JOHN
Last Name:NICHOLAS
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:PO BOX 3810
Mailing Address - Street 2:
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64803
Mailing Address - Country:US
Mailing Address - Phone:417-347-6400
Mailing Address - Fax:
Practice Address - Street 1:3202 MCINTOSH CIR
Practice Address - Street 2:STE LL03
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64804-3646
Practice Address - Country:US
Practice Address - Phone:417-347-6400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2015-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO110180207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100202220AMedicaid
MO208167924Medicaid
MO117796OtherANTHEM
KSP00322601OtherRR MEDICARE
KS100137270CMedicaid
KS110817OtherKS BCBS
KS424135OtherBCBS KS
060061613OtherRR MEDICARE
KS100137270DMedicaid
060061613OtherRR MEDICARE
MO208167924Medicaid
MOM880000Medicare PIN
KS102382Medicare PIN