Healthcare Provider Details

I. General information

NPI: 1295974988
Provider Name (Legal Business Name): ANTONE M NICHOLS D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: MAC NICHOLS D.O.

II. Dates (important events)

Enumeration Date: 02/19/2009
Last Update Date: 06/14/2023
Certification Date: 06/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1723 UNIVERSITY AVE STE B
OXFORD MS
38655-4109
US

IV. Provider business mailing address

1723 UNIVERSITY AVE STE B BOX 315
OXFORD MS
38655
US

V. Phone/Fax

Practice location:
  • Phone: 662-290-9091
  • Fax:
Mailing address:
  • Phone: 662-290-9091
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number21627
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code2083B0002X
TaxonomyObesity Medicine (Preventive Medicine) Physician
License Number21627
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: