MEDICARE: DR. RICHARD MICHAEL NESTRUD M.D.

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	2080N0001X	Neonatal-Perinatal Medicine Physician	ME126444	FL
2	2080N0001X	Neonatal-Perinatal Medicine Physician	C4891	AR
3	2080N0001X	Neonatal-Perinatal Medicine Physician	C-4891	AR

General Provider Information

NPI Number	:	1306897376
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RICHARD MICHAEL NESTRUD M.D.

Provider Business Mailing Address
First Line	:	PO BOX 956
Second Line	:
City	:	PORT ST JOE
State	:	FL
Zip	:	32457-0956
Country	:	US
Telephone Number	:	501-247-5219
Fax Number	:

Provider Business Practice Location Address
First Line	:	108 WASHBOARD CT
Second Line	:
City	:	PORT ST JOE
State	:	FL
Zip	:	32456-4761
Country	:	US
Telephone Number	:	501-225-8821
Fax Number	:	501-225-0917

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

Provider Enumeration Date	:	05/15/2006
Last Update Date	:	02/20/2020

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