Healthcare Provider Details

I. General information

NPI: 1588611206
Provider Name (Legal Business Name): DON K NICOLSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/28/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2058 S DOBSON RD
MESA AZ
85202-6454
US

IV. Provider business mailing address

2058 S DOBSON RD
MESA AZ
85202-6455
US

V. Phone/Fax

Practice location:
  • Phone: 480-730-8479
  • Fax: 480-730-7939
Mailing address:
  • Phone: 480-730-8479
  • Fax: 480-730-7939

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number7678
License Number StateAZ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: