Healthcare Provider Details

I. General information

NPI: 1609097013
Provider Name (Legal Business Name): NICOLAS JOSE LLOSA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2007
Last Update Date: 11/13/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1650 ORLEANS ST
BALTIMORE MD
21287-0013
US

IV. Provider business mailing address

9910 FRANKLIN SQUARE DR STE 2110
BALTIMORE MD
21236-4902
US

V. Phone/Fax

Practice location:
  • Phone: 410-502-8104
  • Fax: 410-955-0028
Mailing address:
  • Phone: 410-933-6423
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number229159
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code2080P0207X
TaxonomyPediatric Hematology & Oncology Physician
License NumberD72879
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: