Provider Demographics
NPI:1922196575
Name:NICHOLS, MARK O (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:O
Last Name:NICHOLS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2600 WILSON ST
Mailing Address - Street 2:
Mailing Address - City:MILES CITY
Mailing Address - State:MT
Mailing Address - Zip Code:59301-5094
Mailing Address - Country:US
Mailing Address - Phone:406-233-2500
Mailing Address - Fax:406-233-2611
Practice Address - Street 1:2600 WILSON ST
Practice Address - Street 2:
Practice Address - City:MILES CITY
Practice Address - State:MT
Practice Address - Zip Code:59301-5094
Practice Address - Country:US
Practice Address - Phone:406-233-2500
Practice Address - Fax:406-233-2611
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2016-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT12569208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A421210Medicaid
CA00A421210Medicaid
CA00A421210Medicare ID - Type Unspecified