Provider Demographics
NPI:1992730444
Name:NICHOLSON, JOHN MALLORY (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:MALLORY
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 1:3043 STATE ROUTE 4
Mailing Address - Street 2:
Mailing Address - City:HUDSON FALLS
Mailing Address - State:NY
Mailing Address - Zip Code:12839-9632
Mailing Address - Country:US
Mailing Address - Phone:518-747-2284
Mailing Address - Fax:518-747-2253
Practice Address - Street 1:3043 STATE ROUTE 4
Practice Address - Street 2:
Practice Address - City:HUDSON FALLS
Practice Address - State:NY
Practice Address - Zip Code:12839-9632
Practice Address - Country:US
Practice Address - Phone:518-747-2284
Practice Address - Fax:518-747-2253
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2010-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001269242084P0800X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
00490944002OtherHEALTHNOW INTEGRATED
10020051OtherCDPHP
53088AOtherMVP
000490944002OtherBLUE SHIELD
00490944002OtherEMPIRE BC/BS BLUE CARD
11123756OtherCAQH
NY00126924Medicaid
00490944002OtherMEDICARE SENIOR BLUE
00490944002OtherEMPIRE BC/BS
04042601887OtherFIDELIS
8U1371OtherBLUE CROSS
53088AOtherMVP
00490944002OtherHEALTHNOW INTEGRATED