Provider Demographics
NPI:1962427179
Name:NICHOLS, MICHAEL C (MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:C
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 319
Mailing Address - Street 2:
Mailing Address - City:KEALAKEKUA
Mailing Address - State:HI
Mailing Address - Zip Code:96750-0319
Mailing Address - Country:US
Mailing Address - Phone:808-322-6692
Mailing Address - Fax:808-322-6693
Practice Address - Street 1:81-948 WAENA 'OIHANA LOOP, SUITE 120
Practice Address - Street 2:CKC BUILDING 9
Practice Address - City:KEALAKEKUA
Practice Address - State:HI
Practice Address - Zip Code:96750
Practice Address - Country:US
Practice Address - Phone:808-322-6692
Practice Address - Fax:808-322-6693
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMD4571174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI011527-01Medicaid
HI0000BDJTMMedicare ID - Type Unspecified
HID36400Medicare UPIN