Provider Demographics
NPI:1649476110
Name:NICHOLS, JAMES THOMAS III (MD)
Entity type:Individual
Prefix:DR
First Name:JAMES
Middle Name:THOMAS
Last Name:NICHOLS
Suffix:III
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 1:3635 PENNSYLVANIA AVE
Mailing Address - Street 2:
Mailing Address - City:MIMS
Mailing Address - State:FL
Mailing Address - Zip Code:32754-5114
Mailing Address - Country:US
Mailing Address - Phone:321-289-2204
Mailing Address - Fax:405-844-1794
Practice Address - Street 1:3635 PENNSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:MIMS
Practice Address - State:FL
Practice Address - Zip Code:32754-5114
Practice Address - Country:US
Practice Address - Phone:321-289-2204
Practice Address - Fax:405-844-1794
Is Sole Proprietor?:No
Enumeration Date:2007-06-22
Last Update Date:2015-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME122364208D00000X, 207P00000X
LA205051208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1010693Medicaid
LAP01045513OtherRAILROAD MCARE
LA1010693Medicaid