Basic Information
| Provider Information | |||||||||
| NPI: | 1083779466 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NICHOLSON | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5350 FRANTZ RD | ||||||||
| Address2: | |||||||||
| City: | DUBLIN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 430164259 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 765 N HAMILTON RD | ||||||||
| Address2: | |||||||||
| City: | GAHANNA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432308703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6145335000 | ||||||||
| FaxNumber: | 6145335059 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/26/2006 | ||||||||
| LastUpdateDate: | 01/05/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 34008840 | OH | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RC0000X | 34.008840 | OH | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 2729908 | 05 | OH | MEDICAID |