MEDICARE: MR. NIKOLAY P MITZOV MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	01056818A	IN
2	207R00000X	Internal Medicine Physician	ME 97001	FL

General Provider Information

NPI Number	:	1255320461
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. NIKOLAY P MITZOV MD

Provider Business Mailing Address
First Line	:	11375 CORTEZ BLVD
Second Line	:
City	:	BROOKSVILLE
State	:	FL
Zip	:	34613-5409
Country	:	US
Telephone Number	:	352-597-6007
Fax Number	:	352-597-6031

Provider Business Practice Location Address
First Line	:	11375 CORTEZ BLVD
Second Line	:
City	:	BROOKSVILLE
State	:	FL
Zip	:	34613-5409
Country	:	US
Telephone Number	:	352-597-6007
Fax Number	:	352-597-6031

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/19/2005
Last Update Date	:	07/08/2007

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