Provider Demographics
NPI:1285601344
Name:NIDA, MAURICE EUGENE (DO)
Entity type:Individual
Prefix:
First Name:MAURICE
Middle Name:EUGENE
Last Name:NIDA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:999 EXECUTIVE PARK BLVD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37660-4632
Mailing Address - Country:US
Mailing Address - Phone:423-224-3250
Mailing Address - Fax:423-224-3258
Practice Address - Street 1:295 WHARTON LN
Practice Address - Street 2:
Practice Address - City:NORTON
Practice Address - State:VA
Practice Address - Zip Code:24273-1541
Practice Address - Country:US
Practice Address - Phone:276-679-0321
Practice Address - Fax:276-679-6498
Is Sole Proprietor?:No
Enumeration Date:2006-03-07
Last Update Date:2012-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0102049965207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA006084877Medicaid
VA017272W82Medicare PIN
F79326Medicare UPIN
VAP00640961Medicare PIN
VA006084877Medicaid
VAV V6478BMedicare PIN