Provider Demographics
NPI:1316334683
Name:NICHOLS, JEFFREY R (DO)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:R
Last Name:NICHOLS
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 1:1000 MINERAL POINT AVE
Mailing Address - Street 2:
Mailing Address - City:JANESVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53548-2940
Mailing Address - Country:US
Mailing Address - Phone:608-756-6611
Mailing Address - Fax:608-756-6177
Practice Address - Street 1:1000 MINERAL POINT AVE
Practice Address - Street 2:
Practice Address - City:JANESVILLE
Practice Address - State:WI
Practice Address - Zip Code:53548
Practice Address - Country:US
Practice Address - Phone:608-756-6611
Practice Address - Fax:608-756-6177
Is Sole Proprietor?:No
Enumeration Date:2015-04-23
Last Update Date:2018-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-144477207P00000X
390200000X
WI69172-21207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1316334683Medicaid
WI1316334683OtherBCBSWI
WI4919OtherMERCYCARE INSURANCE
WIK400494086OtherWI MEDICARE
IL$$$$$$$$$001Medicaid