Provider Demographics
NPI:1104075597
Name:MAYER, NICHOLAS JOHN (DO)
Entity type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:JOHN
Last Name:MAYER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1265 GRAHAM RD STE 1
Mailing Address - Street 2:
Mailing Address - City:FLORISSANT
Mailing Address - State:MO
Mailing Address - Zip Code:63031-8018
Mailing Address - Country:US
Mailing Address - Phone:314-741-1600
Mailing Address - Fax:314-741-1677
Practice Address - Street 1:1265 GRAHAM RD STE 1
Practice Address - Street 2:
Practice Address - City:FLORISSANT
Practice Address - State:MO
Practice Address - Zip Code:63031-8018
Practice Address - Country:US
Practice Address - Phone:314-741-1600
Practice Address - Fax:314-741-1677
Is Sole Proprietor?:No
Enumeration Date:2008-09-10
Last Update Date:2024-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036123985207RN0300X
MO2009007663207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1104075597Medicaid
IL300117440001Medicaid