Healthcare Provider Details

I. General information

NPI: 1528055449
Provider Name (Legal Business Name): DAVID R NICHOLS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2005
Last Update Date: 08/27/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1835 GRANT AVE NEA CLINIC
JONESBORO AR
72403-1960
US

IV. Provider business mailing address

PO BOX 2420
FORT SMITH AR
72902-2420
US

V. Phone/Fax

Practice location:
  • Phone: 870-934-5117
  • Fax: 870-932-3608
Mailing address:
  • Phone: 479-709-7399
  • Fax: 479-709-7053

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License NumberC5475
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: