Healthcare Provider Details

I. General information

NPI: 1770270266
Provider Name (Legal Business Name): NICOLE JEAN BERTAUX DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/24/2023
Last Update Date: 03/05/2026
Certification Date: 03/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

541 OLD COURT ROAD
RANDALLSTOWN MD
21133-5103
US

IV. Provider business mailing address

5401 OLD COURT RD
RANDALLSTOWN MD
21133-5103
US

V. Phone/Fax

Practice location:
  • Phone: 410-521-2200
  • Fax:
Mailing address:
  • Phone: 410-521-2200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberH0106001
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: