Provider Demographics
NPI:1285076380
Name:DAVID NICHOLSON DO, LLC
Entity type:Organization
Organization Name:DAVID NICHOLSON DO, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:NICHOLSON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:937-310-1218
Mailing Address - Street 1:4403 STATE ROUTE 725 STE A1
Mailing Address - Street 2:
Mailing Address - City:BELLBROOK
Mailing Address - State:OH
Mailing Address - Zip Code:45305-2700
Mailing Address - Country:US
Mailing Address - Phone:937-310-1218
Mailing Address - Fax:937-310-1378
Practice Address - Street 1:4403 STATE ROUTE 725 STE A1
Practice Address - Street 2:
Practice Address - City:BELLBROOK
Practice Address - State:OH
Practice Address - Zip Code:45305-2700
Practice Address - Country:US
Practice Address - Phone:937-310-1218
Practice Address - Fax:937-310-1378
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-18
Last Update Date:2023-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34008874207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0087014Medicaid