Provider Demographics
NPI:1699872101
Name:NICHOLSON, JOHN D (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:D
Last Name:NICHOLSON
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:GLACIER CREEK OFFICE PARK- BLDG II
Mailing Address - Street 2:6711 TOWPATH RD., SUITE 175
Mailing Address - City:EAST SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13057-9510
Mailing Address - Country:US
Mailing Address - Phone:315-458-2211
Mailing Address - Fax:315-452-9025
Practice Address - Street 1:GLACIER CREEK OFFICE PARK- BLDG II
Practice Address - Street 2:6711 TOWPATH RD., SUITE 175
Practice Address - City:EAST SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13057-9510
Practice Address - Country:US
Practice Address - Phone:315-458-2211
Practice Address - Fax:315-452-9025
Is Sole Proprietor?:No
Enumeration Date:2006-09-19
Last Update Date:2023-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY133705208600000X, 208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00456919Medicaid
NY35708CMedicare ID - Type Unspecified
NY00456919Medicaid