Healthcare Provider Details

I. General information

NPI: 1063903557
Provider Name (Legal Business Name): C TOLSON NICHOLS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: TOLSON NICHOLS MD

II. Dates (important events)

Enumeration Date: 05/21/2018
Last Update Date: 08/10/2026
Certification Date: 08/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

123 INTERNATIONAL WAY
SPRINGFIELD OR
97477-1047
US

IV. Provider business mailing address

PO BOX 72059
SPRINGFIELD OR
97475-0285
US

V. Phone/Fax

Practice location:
  • Phone: 541-222-6914
  • Fax: 541-326-0924
Mailing address:
  • Phone: 541-222-6914
  • Fax: 541-326-0924

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number7484
License Number StateHI
# 2
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License NumberA175760
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License NumberMD230871
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: