Provider Demographics
NPI:1902892946
Name:NICHOLS, MARK LOVEL (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:LOVEL
Last Name:NICHOLS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:2425 COLEY FOREST PL
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27612-4740
Mailing Address - Country:US
Mailing Address - Phone:919-855-8911
Mailing Address - Fax:919-855-9424
Practice Address - Street 1:250 HOSPICE CIR
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27607-6372
Practice Address - Country:US
Practice Address - Phone:919-828-0890
Practice Address - Fax:919-719-0395
Is Sole Proprietor?:No
Enumeration Date:2005-09-26
Last Update Date:2011-03-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC24472207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8962543Medicaid
NCC85760Medicare UPIN
NC209192FMedicare ID - Type Unspecified