Healthcare Provider Details

I. General information

NPI: 1629090022
Provider Name (Legal Business Name): TIM NICHOLLS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2006
Last Update Date: 07/13/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3700 CALIFORNIA ST DEPARTMENT OF PEDIATRICS
SAN FRANCISCO CA
94118-1618
US

IV. Provider business mailing address

PO BOX 254947
SACRAMENTO CA
95865-4947
US

V. Phone/Fax

Practice location:
  • Phone: 415-923-3291
  • Fax:
Mailing address:
  • Phone: 916-854-6975
  • Fax: 916-854-6864

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA73793
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: