Healthcare Provider Details

I. General information

NPI: 1043589187
Provider Name (Legal Business Name): ANTHONY P. NICOSIA MD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/19/2011
Last Update Date: 03/31/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1502 SE HOLIDAY RD
PORT ST LUCIE FL
34952-5416
US

IV. Provider business mailing address

PO BOX 8540
PORT ST LUCIE FL
34985-8540
US

V. Phone/Fax

Practice location:
  • Phone: 772-332-1757
  • Fax: 772-335-9843
Mailing address:
  • Phone: 772-332-1757
  • Fax: 772-335-9843

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. ANTHONY PETER NICOSIA
Title or Position: PRESIDENT
Credential: M.D.
Phone: 772-332-1757