Provider Demographics
NPI:1427075506
Name:NICHOLAS, THEODORE WILLIAM (MD)
Entity type:Individual
Prefix:DR
First Name:THEODORE
Middle Name:WILLIAM
Last Name:NICHOLAS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3210 N. CROATAN HWY.
Mailing Address - Street 2:SUITE 3
Mailing Address - City:KILL DEVIL HILLS
Mailing Address - State:NC
Mailing Address - Zip Code:27948
Mailing Address - Country:US
Mailing Address - Phone:252-261-5868
Mailing Address - Fax:252-441-7793
Practice Address - Street 1:3210 N. CROATAN HWY.
Practice Address - Street 2:SUITE 3
Practice Address - City:KILL DEVIL HILLS
Practice Address - State:NC
Practice Address - Zip Code:27948
Practice Address - Country:US
Practice Address - Phone:252-261-5868
Practice Address - Fax:252-441-7793
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-16
Last Update Date:2010-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2002-00059208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCB8563OtherMEDCOST PROVIDER NUMBER
NC131G4OtherBC/BS NC PROVIDER NUMBER
NC89131G4Medicaid
NC299811OtherUNITED PROVIDER NUMBER
NCB8563OtherMEDCOST PROVIDER NUMBER
NCH65917Medicare UPIN