Healthcare Provider Details

I. General information

NPI: 1427369131
Provider Name (Legal Business Name): NICOLAI G MEJEVOI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2010
Last Update Date: 09/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3340 TAMIAMI TRL
PORT CHARLOTTE FL
33952-8088
US

IV. Provider business mailing address

3340 TAMIAMI TRL
PORT CHARLOTTE FL
33952-8088
US

V. Phone/Fax

Practice location:
  • Phone: 941-764-5858
  • Fax: 941-764-1657
Mailing address:
  • Phone: 941-764-5858
  • Fax: 941-764-1657

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number036125985
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number036125985
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: