Healthcare Provider Details

I. General information

NPI: 1760986137
Provider Name (Legal Business Name): NICHOLAS OTTO MEADE DO, MS, RD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: NICKY ROTHSTEIN

II. Dates (important events)

Enumeration Date: 03/21/2018
Last Update Date: 09/10/2026
Certification Date: 09/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3100 MACCORKLE AVE SE STE 509
CHARLESTON WV
25304-1226
US

IV. Provider business mailing address

400 ASSOCIATION DR STE 102
CHARLESTON WV
25311-1298
US

V. Phone/Fax

Practice location:
  • Phone: 304-388-6590
  • Fax: 304-388-6595
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberFT665
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number989683
License Number StateNULL
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number5047
License Number StateWV
# 4
Primary TaxonomyN
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number5047
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: