Healthcare Provider Details

I. General information

NPI: 1871560235
Provider Name (Legal Business Name): DONALD E NICHOLS III DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/03/2006
Last Update Date: 05/24/2022
Certification Date: 05/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

180 LEGACY POINT, SUITE 102
CLAYTON GA
30525-5354
US

IV. Provider business mailing address

PO BOX 459
COLBERT GA
30628-0459
US

V. Phone/Fax

Practice location:
  • Phone: 706-886-9441
  • Fax:
Mailing address:
  • Phone: 706-788-3234
  • Fax: 706-788-2936

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberPOD001499
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number016004441
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberPOD001499
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: