MEDICARE: THOMAS MICHAEL NICHOLAS OD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	848	OK

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	848	OTHER	OK	STATE LICENSE NUMER

General Provider Information

NPI Number	:	1467540674
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	THOMAS MICHAEL NICHOLAS OD

Provider Business Mailing Address
First Line	:	1204 W WILLOW RD
Second Line	:	SUITE A
City	:	ENID
State	:	OK
Zip	:	73703-2531
Country	:	US
Telephone Number	:	580-234-2333
Fax Number	:	580-234-0820

Provider Business Practice Location Address
First Line	:	1204 W WILLOW RD
Second Line	:	SUITE A
City	:	ENID
State	:	OK
Zip	:	73703-2531
Country	:	US
Telephone Number	:	580-234-2333
Fax Number	:	580-234-0820

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/11/2006
Last Update Date	:	12/29/2014

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