Provider Demographics
NPI:1720080229
Name:NICHOLS, TIMOTHY P (MD)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:P
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 1:2762 CONTINENTAL DR
Mailing Address - Street 2:STE 201
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70808-3240
Mailing Address - Country:US
Mailing Address - Phone:888-313-5258
Mailing Address - Fax:205-313-5298
Practice Address - Street 1:615 N BONITA AVE
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32401-3623
Practice Address - Country:US
Practice Address - Phone:888-313-5258
Practice Address - Fax:205-313-5298
Is Sole Proprietor?:No
Enumeration Date:2005-08-15
Last Update Date:2016-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL72507207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL255405400Medicaid
FL42672OtherBCBSF GRP # 98513
FL42672OtherBCBSF GRP # 98513
FLF77474Medicare UPIN