Healthcare Provider Details

I. General information

NPI: 1336114891
Provider Name (Legal Business Name): ROGER D NICHOLS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/20/2006
Last Update Date: 05/13/2025
Certification Date: 05/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4747 ARAPAHOE AVE
BOULDER CO
80303-1131
US

IV. Provider business mailing address

42 GARDEN CTR
BROOMFIELD CO
80020-1730
US

V. Phone/Fax

Practice location:
  • Phone: 303-415-7000
  • Fax: 303-438-1351
Mailing address:
  • Phone: 303-465-0401
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number35993
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number35993
License Number StateCO

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: