Provider Demographics
NPI:1538233796
Name:NICHOLSON, DOUGLAS JOHN (DO)
Entity type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:JOHN
Last Name:NICHOLSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Mailing Address - Street 1:1593 E POLSTON AVE
Mailing Address - Street 2:
Mailing Address - City:POST FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83854-5326
Mailing Address - Country:US
Mailing Address - Phone:208-262-2300
Mailing Address - Fax:208-262-2390
Practice Address - Street 1:315 W DALTON AVE STE B
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83815-8600
Practice Address - Country:US
Practice Address - Phone:208-209-2066
Practice Address - Fax:208-262-2076
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2019-05-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IDO-310207Q00000X, 207Q00000X
NE565207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1538233796Medicaid