Provider Demographics
NPI:1770744112
Name:ABSALOM, NICHOLAS MICHAEL (MD)
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:MICHAEL
Last Name:ABSALOM
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 1:8750 MEDITERRANEAN DR
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75238-3742
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:239-208-3994
Practice Address - Street 1:7259 S BINGHAM JUNCTION BLVD
Practice Address - Street 2:
Practice Address - City:MIDVALE
Practice Address - State:UT
Practice Address - Zip Code:84047-4860
Practice Address - Country:US
Practice Address - Phone:801-264-6400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-18
Last Update Date:2025-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD1858002084N0400X
LA3107212084N0400X, 2084N0400X
FLME1341602084N0400X
TXP03292084N0400X, 2084N0400X
IL0361486302084N0400X
MO20200039282084N0400X
IDMC-06022084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH3115814Medicaid