Basic Information
| Provider Information | |||||||||
| NPI: | 1619080561 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NICHOLS | ||||||||
| FirstName: | JOE | ||||||||
| MiddleName: | DANIEL | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1011 SOUTH WILLIAM | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | TX | ||||||||
| PostalCode: | 755513245 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9037962868 | ||||||||
| FaxNumber: | 9037960826 | ||||||||
| Practice Location | |||||||||
| Address1: | 1011 SOUTH WILLIAM | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | TX | ||||||||
| PostalCode: | 755513245 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9037962868 | ||||||||
| FaxNumber: | 9037960826 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/16/2006 | ||||||||
| LastUpdateDate: | 07/07/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 07/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | D3947 | TX | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 123277903 | 05 | TX | MEDICAID | 118076 | 01 | CHIPS | OTHER | 080022253 | 01 | MEDICARE RR | OTHER | 97276 | 01 | AR | BCBS | OTHER | 806052 | 01 | TX | BCBS | OTHER | A004 | 01 | CHAMPUS | OTHER |