Provider Demographics
NPI:1497968655
Name:MAKSIM, NICHOLAS EUGENE (DO, RPH)
Entity type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:EUGENE
Last Name:MAKSIM
Suffix:
Gender:M
Credentials:DO, RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 N MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:LONDON
Mailing Address - State:OH
Mailing Address - Zip Code:43140-1115
Mailing Address - Country:US
Mailing Address - Phone:740-845-7700
Mailing Address - Fax:740-845-7701
Practice Address - Street 1:247 S BURNETT ROAD
Practice Address - Street 2:SUITE 120
Practice Address - City:SPRINGFIELD
Practice Address - State:OH
Practice Address - Zip Code:45505
Practice Address - Country:US
Practice Address - Phone:740-845-7700
Practice Address - Fax:740-845-7701
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-07
Last Update Date:2024-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH58-001639207R00000X
OH34.009062207RC0000X
OH34009062207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3147919Medicaid
OHMA4319751Medicare PIN