Healthcare Provider Details

I. General information

NPI: 1770495202
Provider Name (Legal Business Name): GEORGINA NICHOLS MD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/21/2026
Last Update Date: 09/21/2026
Certification Date: 09/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

915 MIDDLE RIVER DR STE 213
FORT LAUDERDALE FL
33304-3560
US

IV. Provider business mailing address

4704 SW 160TH AVE APT 220
MIRAMAR FL
33027-5707
US

V. Phone/Fax

Practice location:
  • Phone: 561-529-5077
  • Fax: 877-561-5267
Mailing address:
  • Phone: 561-529-5077
  • Fax: 877-561-5267

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: GEORGINA NICHOLS
Title or Position: CEO
Credential: MD
Phone: 561-529-5077