Healthcare Provider Details

I. General information

NPI: 1497048318
Provider Name (Legal Business Name): NIKOLA ALEXANDER LETHAM D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2011
Last Update Date: 05/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

826 DAVIS ST
BLACKSBURG VA
24060-7010
US

IV. Provider business mailing address

2000 HEALTH PARK DR FL HP2
BRENTWOOD TN
37027-4525
US

V. Phone/Fax

Practice location:
  • Phone: 540-443-0500
  • Fax: 540-553-0526
Mailing address:
  • Phone: 615-373-7600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number2015-00756
License Number StateNC
# 3
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number0102204905
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: