Healthcare Provider Details

I. General information

NPI: 1366428096
Provider Name (Legal Business Name): THOMAS C. NICHOLSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/15/2005
Last Update Date: 04/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3612 23RD STREET
LUBBOCK TX
79410-1326
US

IV. Provider business mailing address

3420 22ND PL
LUBBOCK TX
79410-1314
US

V. Phone/Fax

Practice location:
  • Phone: 806-793-8787
  • Fax: 806-793-0150
Mailing address:
  • Phone: 806-725-5844
  • Fax: 806-723-6532

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number89-82
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License NumberM9543
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: