Provider Demographics
NPI:1457562225
Name:NICHOLS, JEFFREY N (MD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:N
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 1:542 E 5TH ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10009-6531
Mailing Address - Country:US
Mailing Address - Phone:212-358-6255
Mailing Address - Fax:212-358-6269
Practice Address - Street 1:542 E 5TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10009-6531
Practice Address - Country:US
Practice Address - Phone:212-358-6255
Practice Address - Fax:212-358-6269
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY131897-1207RG0300X, 207RH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Not Answered207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00510178Medicaid
CO5259Medicare UPIN