Provider Demographics
NPI:1720100142
Name:NICHOLS, GLENN ROBERT (DO)
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:ROBERT
Last Name:NICHOLS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 KING PHILIP AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH DEERFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01373-1127
Mailing Address - Country:US
Mailing Address - Phone:413-772-6337
Mailing Address - Fax:413-772-0841
Practice Address - Street 1:16 KING PHILIP AVE
Practice Address - Street 2:
Practice Address - City:SOUTH DEERFIELD
Practice Address - State:MA
Practice Address - Zip Code:01373-1127
Practice Address - Country:US
Practice Address - Phone:413-772-6337
Practice Address - Fax:413-772-0841
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-05
Last Update Date:2017-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAMA2078156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician