Provider Demographics
NPI:1558438788
Name:NICKOLAS, THOMAS LOUIS (MD)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:LOUIS
Last Name:NICKOLAS
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 7412011
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60674-2011
Mailing Address - Country:US
Mailing Address - Phone:314-454-7775
Mailing Address - Fax:314-996-3087
Practice Address - Street 1:4921 PARKVIEW PL
Practice Address - Street 2:DIV IM BONE AND MINERAL, STE 5C
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-1032
Practice Address - Country:US
Practice Address - Phone:314-454-7775
Practice Address - Fax:314-996-3087
Is Sole Proprietor?:No
Enumeration Date:2006-11-30
Last Update Date:2025-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2024049980207RN0300X, 207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
No207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO200154745Medicaid
NY02381235Medicaid
NY6X8701Medicare ID - Type Unspecified