Healthcare Provider Details

I. General information

NPI: 1538194766
Provider Name (Legal Business Name): KEITH CAMERON NICHOLS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2006
Last Update Date: 04/27/2026
Certification Date: 04/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1096 W INDIANTOWN RD STE 100
JUPITER FL
33458-6855
US

IV. Provider business mailing address

900 VILLAGE SQUARE XING STE 290
PALM BEACH GARDENS FL
33410-4552
US

V. Phone/Fax

Practice location:
  • Phone: 561-222-2200
  • Fax: 561-222-2201
Mailing address:
  • Phone: 239-313-2517
  • Fax: 239-313-2555

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License NumberME178296
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number01010406236
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: