Provider Demographics
NPI:1740316330
Name:NICODEMUS, CHRISTOPHER F (MD)
Entity type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:F
Last Name:NICODEMUS
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 1:197 8TH ST
Mailing Address - Street 2:SUITE 706
Mailing Address - City:CHARLESTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02129-4208
Mailing Address - Country:US
Mailing Address - Phone:781-416-1506
Mailing Address - Fax:
Practice Address - Street 1:UNITHER
Practice Address - Street 2:15WALNUT ST, STE300
Practice Address - City:WELLESLEY
Practice Address - State:MA
Practice Address - Zip Code:02481
Practice Address - Country:US
Practice Address - Phone:781-416-1506
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA56462207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine