Healthcare Provider Details

I. General information

NPI: 1316960370
Provider Name (Legal Business Name): THOMAS NICOTRI JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2006
Last Update Date: 09/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

229 W CAUSEWAY APPROACH
MANDEVILLE LA
70448
US

IV. Provider business mailing address

PO BOX 3780
TUPELO MS
38803-3780
US

V. Phone/Fax

Practice location:
  • Phone: 504-722-7684
  • Fax:
Mailing address:
  • Phone: 318-841-9526
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License NumberMD.023801
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: