Provider Demographics
NPI:1730185505
Name:NICHOLAS, PETER D JR (MD)
Entity type:Individual
Prefix:DR
First Name:PETER
Middle Name:D
Last Name:NICHOLAS
Suffix:JR
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 1:2760 CENTURY BLVD
Mailing Address - Street 2:
Mailing Address - City:WYOMISSING
Mailing Address - State:PA
Mailing Address - Zip Code:19610-3359
Mailing Address - Country:US
Mailing Address - Phone:610-375-4251
Mailing Address - Fax:610-375-6210
Practice Address - Street 1:2760 CENTURY BLVD
Practice Address - Street 2:
Practice Address - City:WYOMISSING
Practice Address - State:PA
Practice Address - Zip Code:19610-3359
Practice Address - Country:US
Practice Address - Phone:610-375-4251
Practice Address - Fax:610-375-6210
Is Sole Proprietor?:No
Enumeration Date:2005-06-24
Last Update Date:2010-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD021072E174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0006369910001Medicaid
PA1730185505OtherNPI
PA660000792Medicare PIN
PA123340F5JMedicare PIN
C30831Medicare UPIN
PA0277720001Medicare NSC