Healthcare Provider Details

I. General information

NPI: 1528314259
Provider Name (Legal Business Name): NOLAN K MOTT D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2012
Last Update Date: 06/30/2023
Certification Date: 06/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 MEMORIAL MEDICAL PKWY
DAYTONA BEACH FL
32117-5167
US

IV. Provider business mailing address

155 CRYSTAL RUN RD
MIDDLETOWN NY
10941-4028
US

V. Phone/Fax

Practice location:
  • Phone: 407-975-0410
  • Fax: 407-975-0407
Mailing address:
  • Phone: 845-703-6999
  • Fax: 845-703-6297

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number273061
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number273061
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberOS11720
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: