Healthcare Provider Details

I. General information

NPI: 1558781179
Provider Name (Legal Business Name): GEORGINA NICHOLS M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/22/2014
Last Update Date: 06/04/2026
Certification Date: 06/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

915 MIDDLE RIVER DR STE 213
FORT LAUDERDALE FL
33304-3560
US

IV. Provider business mailing address

915 MIDDLE RIVER DR STE 213
FORT LAUDERDALE FL
33304-3560
US

V. Phone/Fax

Practice location:
  • Phone: 561-529-5570
  • Fax: 877-561-5267
Mailing address:
  • Phone: 561-529-5077
  • Fax: 887-561-5267

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number175636
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License NumberME151972
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: