Healthcare Provider Details

I. General information

NPI: 1235391012
Provider Name (Legal Business Name): SYDNEY NICHOLS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2008
Last Update Date: 01/31/2024
Certification Date: 01/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7955 BAY ST STE 2
SEBASTIAN FL
32958-3282
US

IV. Provider business mailing address

7955 BAY ST STE 2
SEBASTIAN FL
32958-3282
US

V. Phone/Fax

Practice location:
  • Phone: 772-388-9155
  • Fax: 772-388-9154
Mailing address:
  • Phone: 772-388-9155
  • Fax: 772-388-9154

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number04-35889
License Number StateKS
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME153584
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: