Provider Demographics
NPI:1982602454
Name:NICHOLAS, RADOSLAV SB (MD)
Entity Type:Individual
Prefix:DR
First Name:RADOSLAV
Middle Name:SB
Last Name:NICHOLAS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:RADOSLAV
Other - Middle Name:STEVAN
Other - Last Name:NICHOLAS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX CC
Mailing Address - Street 2:
Mailing Address - City:BIG STONE GAP
Mailing Address - State:VA
Mailing Address - Zip Code:24219-0690
Mailing Address - Country:US
Mailing Address - Phone:276-523-7938
Mailing Address - Fax:276-523-7028
Practice Address - Street 1:1990 HOLTON AVE E
Practice Address - Street 2:
Practice Address - City:BIG STONE GAP
Practice Address - State:VA
Practice Address - Zip Code:24219-3350
Practice Address - Country:US
Practice Address - Phone:276-523-7938
Practice Address - Fax:276-523-7028
Is Sole Proprietor?:No
Enumeration Date:2005-07-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01010365562085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
B42721Medicare UPIN