Healthcare Provider Details

I. General information

NPI: 1700223674
Provider Name (Legal Business Name): FRED HERBERT NICHOLLS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/31/2013
Last Update Date: 05/31/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 PARNASSUS AVE MU 320
SAN FRANCISCO CA
94143-2203
US

IV. Provider business mailing address

500 PARNASSUS AVE MU 320
SAN FRANCISCO CA
94143-2203
US

V. Phone/Fax

Practice location:
  • Phone: 415-476-6043
  • Fax:
Mailing address:
  • Phone: 415-476-6043
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberA125674
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: