Provider Demographics
NPI:1528055449
Name:NICHOLS, DAVID R (MD)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:R
Last Name:NICHOLS
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:PO BOX 2420
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72902-2420
Mailing Address - Country:US
Mailing Address - Phone:479-709-7399
Mailing Address - Fax:479-709-7053
Practice Address - Street 1:1835 GRANT AVE
Practice Address - Street 2:NEA CLINIC
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72403-1960
Practice Address - Country:US
Practice Address - Phone:870-934-5117
Practice Address - Fax:870-932-3608
Is Sole Proprietor?:No
Enumeration Date:2005-10-05
Last Update Date:2007-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC5475207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR53842Medicare ID - Type Unspecified
ARD17020Medicare UPIN