Basic Information
Provider Information | |||||||||
NPI: | 1831121193 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | NICOLAS | ||||||||
FirstName: | VICTOR | ||||||||
MiddleName: | T | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 640929 | ||||||||
Address2: |   | ||||||||
City: | CINCINNATI | ||||||||
State: | OH | ||||||||
PostalCode: | 452640929 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5137270748 | ||||||||
FaxNumber: | 9372930960 | ||||||||
Practice Location | |||||||||
Address1: | 105 MCKNIGHT DRIVE | ||||||||
Address2: |   | ||||||||
City: | MIDDLETOWN | ||||||||
State: | OH | ||||||||
PostalCode: | 450444898 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5134242111 | ||||||||
FaxNumber: | 5134205662 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/07/2006 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 35053137N | OH | X |   | Allopathic & Osteopathic Physicians | Anesthesiology |   | 207LP2900X | 35053137 | OH | X |   | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine |
ID Information
ID | Type | State | Issuer | Description | 0628182 | 05 | OH |   | MEDICAID | 000000015848 | 01 | OH | ANTHEM | OTHER | 2020092 | 01 | OH | UNITED HEALTHCARE | OTHER |