Provider Demographics
NPI:1083671622
Name:NICODEMUS, HECTOR (MD)
Entity Type:Individual
Prefix:
First Name:HECTOR
Middle Name:
Last Name:NICODEMUS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:804 SCOTT NIXON MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30907-2464
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2730 UNIVERSITY BLVD W
Practice Address - Street 2:STE 104
Practice Address - City:WHEATON
Practice Address - State:MD
Practice Address - Zip Code:20902-1905
Practice Address - Country:US
Practice Address - Phone:301-942-8799
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-27
Last Update Date:2007-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD62453207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD016872H41Medicare PIN