Provider Demographics
NPI:1780967232
Name:NICHOLS, SANDRA BRUCE (MD)
Entity type:Individual
Prefix:DR
First Name:SANDRA
Middle Name:BRUCE
Last Name:NICHOLS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:SANDRA
Other - Middle Name:DENISE
Other - Last Name:NICHOLS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:12706 YOUNG LN
Mailing Address - Street 2:
Mailing Address - City:NORTH POTOMAC
Mailing Address - State:MD
Mailing Address - Zip Code:20878-6112
Mailing Address - Country:US
Mailing Address - Phone:301-947-6774
Mailing Address - Fax:131-094-7677
Practice Address - Street 1:12018 SUNRISE VALLEY DR
Practice Address - Street 2:SUITE 400
Practice Address - City:RESTON
Practice Address - State:VA
Practice Address - Zip Code:20191-3432
Practice Address - Country:US
Practice Address - Phone:301-448-6550
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-21
Last Update Date:2011-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD60180207Q00000X, 302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine