Basic Information
Provider Information | |||||||||
NPI: | 1376520643 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | NICHOLAS | ||||||||
FirstName: | DAVID | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | DO | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1340 HAL GREER BLVD | ||||||||
Address2: |   | ||||||||
City: | HUNTINGTON | ||||||||
State: | WV | ||||||||
PostalCode: | 257013804 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3045262200 | ||||||||
FaxNumber: | 3043991507 | ||||||||
Practice Location | |||||||||
Address1: | 1340 HAL GREER BLVD | ||||||||
Address2: |   | ||||||||
City: | HUNTINGTON | ||||||||
State: | WV | ||||||||
PostalCode: | 257013804 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3045262200 | ||||||||
FaxNumber: | 3043991507 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/28/2005 | ||||||||
LastUpdateDate: | 04/13/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 04/13/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 1452 | WV | Y |   | Allopathic & Osteopathic Physicians | Emergency Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 2072386 | 05 | OH |   | MEDICAID | 64942931 | 05 | KY |   | MEDICAID | 1376520643 | 05 | AL |   | MEDICAID | 1045606 | 01 | WV | WV DWC | OTHER | 1376520643 | 05 | WV |   | MEDICAID | 000857496 | 01 | WV | WV BCBS | OTHER | Q054110 | 05 | TN |   | MEDICAID | WV0524A | 01 | WV | MEDICARE FOR CHHI | OTHER |