Provider Demographics
NPI:1063576049
Name:NICHOLSON, DEBORAH J (MD)
Entity type:Individual
Prefix:DR
First Name:DEBORAH
Middle Name:J
Last Name:NICHOLSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:DEBORAH
Other - Middle Name:J
Other - Last Name:JOYNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:2 W ROLLING CROSSROADS
Mailing Address - Street 2:SUITE 104
Mailing Address - City:CATONSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21228-6208
Mailing Address - Country:US
Mailing Address - Phone:410-719-9630
Mailing Address - Fax:410-719-9672
Practice Address - Street 1:2 W ROLLING CROSSROADS
Practice Address - Street 2:SUITE 104
Practice Address - City:CATONSVILLE
Practice Address - State:MD
Practice Address - Zip Code:21228-6208
Practice Address - Country:US
Practice Address - Phone:410-719-9630
Practice Address - Fax:410-719-9672
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-21
Last Update Date:2014-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0033702174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD28361100Medicaid
MD2597Medicare ID - Type Unspecified
MD28361100Medicaid