Individual
MATEO F NICHOLSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
DO
Contact information
Practice address
2231 CAREW ST, FORT WAYNE, IN 46805-4713
(260) 425-6780
(260) 373-9225
Mailing address
11109 PARKVIEW PLAZA DR # 117, FORT WAYNE, IN 46845-1701
Taxonomy
Speciality
Code
Description
License number
State
207R00000X
Internal Medicine Physician
125074919
IL
208100000X
Physical Medicine & Rehabilitation Physician
Primary
02007853A
IN
390200000X
Student in an Organized Health Care Education/Training Program
33866
MN
390200000X
Student in an Organized Health Care Education/Training Program
75957-21
WI
390200000X
Student in an Organized Health Care Education/Training Program
—
WI
Other
Enumeration date
04/02/2019
Last updated
10/02/2024
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