=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508941758
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DAVID W NICHOLS MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/26/2006
-----------------------------------------------------
Last Update Date | 04/30/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 480 W SOUTHLAKE BLVD STE 133
-----------------------------------------------------
City | SOUTHLAKE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76092-6162
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-329-9234
-----------------------------------------------------
Fax | 817-329-9239
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 733784
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75373-3784
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 682-885-1855
-----------------------------------------------------
Fax | 682-885-1396
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | J6631
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------