Healthcare Provider Details

I. General information

NPI: 1912757188
Provider Name (Legal Business Name): JOSE IGNACIO NOLAZCO MD, MMSC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2024
Last Update Date: 09/16/2026
Certification Date: 09/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5503 S CONGRESS AVE STE 206
ATLANTIS FL
33462-6626
US

IV. Provider business mailing address

5503 S CONGRESS AVE STE 206
ATLANTIS FL
33462-6626
US

V. Phone/Fax

Practice location:
  • Phone: 561-964-1636
  • Fax: 561-964-1636
Mailing address:
  • Phone: 561-964-1632
  • Fax: 561-964-1636

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License NumberME184636
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: