Provider Demographics
NPI:1962422253
Name:NICHOLSON, CHARLES RICHARD (OD)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:RICHARD
Last Name:NICHOLSON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11513 W FAIRVIEW AVE
Mailing Address - Street 2:SUITE 106
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83713-7886
Mailing Address - Country:US
Mailing Address - Phone:208-322-8439
Mailing Address - Fax:208-322-8433
Practice Address - Street 1:11513 W FAIRVIEW AVE
Practice Address - Street 2:SUITE 106
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83713-7886
Practice Address - Country:US
Practice Address - Phone:208-322-8439
Practice Address - Fax:208-322-8433
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2009-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDODP-100134152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1590015OtherMEDICARE PTAN
ID000010162496OtherREGENCE BLUE SHIELD
ID000010162496OtherREGENCE BLUE SHIELD