Provider Demographics
NPI:1457436537
Name:NICHOLSON, CARL V (OD)
Entity Type:Individual
Prefix:DR
First Name:CARL
Middle Name:V
Last Name:NICHOLSON
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 1:709 E COLORADO BLVD STE 101
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91101-2125
Mailing Address - Country:US
Mailing Address - Phone:626-795-3453
Mailing Address - Fax:626-795-0047
Practice Address - Street 1:709 E COLORADO BLVD STE 101
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91101-2125
Practice Address - Country:US
Practice Address - Phone:626-795-3453
Practice Address - Fax:626-795-0047
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-26
Last Update Date:2023-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA152W00000X152W00000X
SC2113152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU52600Medicare UPIN