=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700936788
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LEON TERRENZE NICHOLS M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/11/2007
-----------------------------------------------------
Last Update Date | 09/11/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1901 1ST AVE
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10029-7404
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-423-8302
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 144 WAVERLY RD
-----------------------------------------------------
City | SCARSDALE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10583-6759
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 914-632-9442
-----------------------------------------------------
Fax | 914-632-1355
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 111462
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number | 111462
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------