Provider Demographics
NPI:1992809941
Name:NICHOLS, JEFFREY WILLIAM (MD)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:WILLIAM
Last Name:NICHOLS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:694 W IRVING PARK RD APT B8
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60613-3161
Mailing Address - Country:US
Mailing Address - Phone:773-929-3685
Mailing Address - Fax:708-798-2317
Practice Address - Street 1:18440 GOVERNORS HWY
Practice Address - Street 2:
Practice Address - City:HOMEWOOD
Practice Address - State:IL
Practice Address - Zip Code:60430-2911
Practice Address - Country:US
Practice Address - Phone:708-798-2191
Practice Address - Fax:708-798-2317
Is Sole Proprietor?:No
Enumeration Date:2006-09-11
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036069554207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036069554Medicaid
IL036069554Medicaid
C45657Medicare UPIN