Healthcare Provider Details

I. General information

NPI: 1972008852
Provider Name (Legal Business Name): ENZO ANDRE NICOSIA DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2018
Last Update Date: 06/25/2022
Certification Date: 06/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

119 OAKFIELD DR
BRANDON FL
33511-5779
US

IV. Provider business mailing address

119 OAKFIELD DR
BRANDON FL
33511-5779
US

V. Phone/Fax

Practice location:
  • Phone: 813-681-5551
  • Fax:
Mailing address:
  • Phone: 813-681-5551
  • Fax: 813-916-2944

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberOS17524
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: