Provider Demographics
NPI:1699713552
Name:NICHOLS, COURTNEY G (DPM)
Entity type:Individual
Prefix:DR
First Name:COURTNEY
Middle Name:G
Last Name:NICHOLS
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6499 S MASON MONTGOMERY RD
Mailing Address - Street 2:SUITE C
Mailing Address - City:MASON
Mailing Address - State:OH
Mailing Address - Zip Code:45040-1764
Mailing Address - Country:US
Mailing Address - Phone:513-229-0101
Mailing Address - Fax:513-860-1002
Practice Address - Street 1:27378 W OVIATT RD
Practice Address - Street 2:
Practice Address - City:BAY VILLAGE
Practice Address - State:OH
Practice Address - Zip Code:44140-2139
Practice Address - Country:US
Practice Address - Phone:440-871-4700
Practice Address - Fax:440-871-4702
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-03
Last Update Date:2007-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36-00-3269-N213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2294324Medicaid
OHU87739Medicare UPIN
OH4062452Medicare PIN