1811915747 NPI number — DR. NICKOLAS JOHN COLLUCCI D.O.

Table of content: DR. NICKOLAS JOHN COLLUCCI D.O. (NPI 1811915747)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811915747 NPI number — DR. NICKOLAS JOHN COLLUCCI D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
COLLUCCI
Provider First Name:
NICKOLAS
Provider Middle Name:
JOHN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.O.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1811915747
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/21/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 279
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FLAGLER BEACH
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32136-0279
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
386-586-5344
Provider Business Mailing Address Fax Number:
386-586-5450

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
21 HOSPITAL DR
Provider Second Line Business Practice Location Address:
SUITE 260
Provider Business Practice Location Address City Name:
PALM COAST
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32164-2452
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
386-586-5344
Provider Business Practice Location Address Fax Number:
386-586-5450
Provider Enumeration Date:
07/18/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  OS4153 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 202K00000X , with the licence number: OS4153 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2024 www.npivalidator.com