Provider Demographics
NPI:1871513895
Name:NICHOLAS, WILLIAM CLYDE (MD)
Entity type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:CLYDE
Last Name:NICHOLAS
Suffix:
Gender:M
Credentials:MD
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Other - Credentials:
Mailing Address - Street 1:PO BOX 24146
Mailing Address - Street 2:UNIVERSITY PHYSICIANS PLLC
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39225-4146
Mailing Address - Country:US
Mailing Address - Phone:601-984-5525
Mailing Address - Fax:601-984-5769
Practice Address - Street 1:2500 NORTH STATE STREET
Practice Address - Street 2:DEPARTMENT OF MEDICINE DIVISION OF ENDOCRINOLOGY
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4500
Practice Address - Country:US
Practice Address - Phone:601-984-5525
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2012-06-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MS08290207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0017122Medicaid
MSRR 110127661OtherRAILROAD
LA1960802Medicaid
MS0017122Medicaid
MS302I467196Medicare PIN
MSP00629131Medicare PIN
MS512I110032Medicare PIN
MSB30453Medicare UPIN