Healthcare Provider Details

I. General information

NPI: 1487727921
Provider Name (Legal Business Name): THOMAS NICOTRI JR MD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/15/2006
Last Update Date: 11/05/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1305 W CAUSEWAY APPROACH STE 209
MANDEVILLE LA
70471-3043
US

IV. Provider business mailing address

PO BOX 1536
MANDEVILLE LA
70470-1536
US

V. Phone/Fax

Practice location:
  • Phone: 985-626-6996
  • Fax: 985-626-6995
Mailing address:
  • Phone: 985-662-6699
  • Fax: 985-626-6995

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License Number023801
License Number StateLA

VIII. Authorized Official

Name: DR. THOMAS NICOTRI JR.
Title or Position: PRESIDENT
Credential: MD
Phone: 985-626-6996