Provider Demographics
NPI:1932370681
Name:NICHOLSON, CAMERON LEE (MD)
Entity Type:Individual
Prefix:
First Name:CAMERON
Middle Name:LEE
Last Name:NICHOLSON
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:P.O. BOX 2147
Mailing Address - Street 2:
Mailing Address - City:FT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33902-2147
Mailing Address - Country:US
Mailing Address - Phone:239-343-5553
Mailing Address - Fax:239-343-5321
Practice Address - Street 1:9981 S HEALTHPARK DR
Practice Address - Street 2:SUITE 156
Practice Address - City:FT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33908-3618
Practice Address - Country:US
Practice Address - Phone:239-343-5333
Practice Address - Fax:239-343-5321
Is Sole Proprietor?:No
Enumeration Date:2008-03-20
Last Update Date:2021-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH57.006511208000000X
FLME102793208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000452700Medicaid