Healthcare Provider Details

I. General information

NPI: 1679555270
Provider Name (Legal Business Name): ROMAINE CHARLES NICHOLS JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/18/2005
Last Update Date: 10/20/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2015 JEFFERSON ST
JACKSONVILLE FL
32206-3531
US

IV. Provider business mailing address

PO BOX 116304
ATLANTA GA
30368-6304
US

V. Phone/Fax

Practice location:
  • Phone: 904-588-1800
  • Fax:
Mailing address:
  • Phone: 904-588-1800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License NumberME0056785
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: