Provider Demographics
NPI:1770608267
Name:NICOLA, KIM RICHARD (MD)
Entity type:Individual
Prefix:
First Name:KIM
Middle Name:RICHARD
Last Name:NICOLA
Suffix:
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 1:2928 BUSBEE PKWY NW
Mailing Address - Street 2:530
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30144-4820
Mailing Address - Country:US
Mailing Address - Phone:770-627-4950
Mailing Address - Fax:770-627-4950
Practice Address - Street 1:2928 BUSBEE PKWY NW
Practice Address - Street 2:530
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30144-4820
Practice Address - Country:US
Practice Address - Phone:770-627-4950
Practice Address - Fax:770-627-4950
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-21
Last Update Date:2008-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA027881174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00312375DMedicaid
GA00312375DMedicaid